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AVITA PHARMACY 1058
RWII27407 Central Carolina Health Network
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Covered Entity Details
Entity Name
Central Carolina Health Network
Subdivision Name
Type
Ryan White Part B
340B ID
RWII27407
Entity Address
1 Centerview Drive
Suite 202
Greensboro, NC 27407
Grant Number
X07HA00051
Participating Start Date
1/1/2017
Last Recertification Date
3/3/2025
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
11/1/2016
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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