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AVITA PHARMACY 1029
STD75235 Resource Center of Dallas
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Covered Entity Details
Entity Name
Resource Center of Dallas
Subdivision Name
Nelson-Tebedo Clinic
Type
Sexually Transmitted Diseases
340B ID
STD75235
Entity Address
2603 Inwood
Dallas, TX 75235
Grant Number
NH25PS005182
Participating Start Date
4/1/2017
Last Recertification Date
5/5/2025
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
4/20/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Marisa Elliott, Chief Operating Officer
(214) 540-4454
Contract Pharmacy Representative
Avita Pharmacy
JERRY PURCELL, CEO/PRESIDENT
(504) 905-4587
Signed By Date
4/20/2017
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