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AVITA PHARMACY 1029
RWI78212 BEAT AIDS COALITION TRUST
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Covered Entity Details
Entity Name
BEAT AIDS COALITION TRUST
Subdivision Name
Type
Ryan White Part A
340B ID
RWI78212
Entity Address
208 W EUCLID AVE
SAN ANTONIO, TX 78212
Grant Number
H89HA31891
Participating Start Date
1/1/2017
Last Recertification Date
2/15/2025
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
10/21/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Avita Pharmacy
JERRY PURCELL, CEO/PRESIDENT
(504) 905-4587
Signed By Date
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