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AVITA PHARMACY 1058
STD29621 AID UPSTATE
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Covered Entity Details
Entity Name
AID UPSTATE
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD29621
Entity Address
118 MONTGOMERY DRIVE
ANDERSON, SC 29621
Grant Number
NH25PS005150
Participating Start Date
4/1/2017
Last Recertification Date
5/8/2024
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
1/23/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Duplicate contract pharmacy record
Contacts
Covered Entity Signing Official
B ANDREW HALL, CEO
(864) 250-0607 Ext: 6208
Contract Pharmacy Representative
Avita Pharmacy
JERRY PURCELL, CEO/PRESIDENT
(504) 905-4587
Signed By Date
1/23/2017
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