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AVITA PHARMACY 1028
STD78208 San Antonio AIDS Foundation
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Covered Entity Details
Entity Name
San Antonio AIDS Foundation
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD78208
Entity Address
818 E. Grayson St
San Antonio, TX 78208
Grant Number
NU62PS924529
Participating Start Date
4/1/2017
Last Recertification Date
5/5/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1028
Pharmacy Address
340B PARTNERS PHARMACY-DALLAS LLC DBA AV
750 FORT WORTH AVE STE H100
DALLAS, TX 75208-1811
Pharmacy Comments
Contract Details
Approval Date
2/2/2017
Contract Begin Date
4/1/2017
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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