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AVITA PHARMACY 1058
STD35233 BIRMINGHAM AIDS OUTREACH INC.
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Covered Entity Details
Entity Name
BIRMINGHAM AIDS OUTREACH INC.
Subdivision Name
Magic City Wellness Center
Type
Sexually Transmitted Diseases
340B ID
STD35233
Entity Address
3220 5th Avenue South
Suite 100
Birmingham, AL 35222
Grant Number
5 NH25PS005129-04
Participating Start Date
1/1/2017
Last Recertification Date
5/10/2024
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1058
Pharmacy Address
MEDEXPRESS PHARMACY, LTD. DBA AVITA PHAR
1431 W. INNES ST.
SALISBURY, NC 28144
Pharmacy Comments
Contract Details
Approval Date
10/31/2016
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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