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AVITA PHARMACY 1029
HV01710A AIDS Arms, Inc.d/b/a Prism Health North Texas
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Covered Entity Details
Entity Name
AIDS Arms, Inc.d/b/a Prism Health North Texas
Subdivision Name
South Dallas Clinic
Type
Ryan White Part C
340B ID
HV01710A
Entity Address
4922 Spring Ave
Dallas, TX 75210-1359
Grant Number
H76HA01710
Participating Start Date
7/1/2016
Last Recertification Date
3/3/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1029
Pharmacy Address
340B PARTNERS PHARMACY LLC D/B/A AVITA P
303 N FRIO ST
SUITE 102
SAN ANTONIO, TX 78207-3034
Pharmacy Comments
Contract Details
Approval Date
4/14/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/31/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Avita Drugs
JERRY PURCELL, FOUNDER
(504) 905-4587
Signed By Date
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