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AVITA PHARMACY 1038
STD78752 Vivent Health Texas, Inc.
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Covered Entity Details
Entity Name
Vivent Health Texas, Inc.
Subdivision Name
AIDS Services of Austin
Type
Sexually Transmitted Diseases
340B ID
STD78752
Entity Address
104 E Highland Mall Blvd
Suite 100
Austin, TX 78752
Grant Number
NH25PS005182
Participating Start Date
7/1/2017
Last Recertification Date
5/5/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1038
Pharmacy Address
AVITA DRUGS LLC-NOLA 2 D/B/A AVITA PHARM
3308 TULANE AVE STE 102
NEW ORLEANS, LA 70119-7170
Pharmacy Comments
Contract Details
Approval Date
4/24/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Avita Pharmacy
JERRY PURCELL, CEO/PRESIDENT
(504) 905-4587
Signed By Date
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