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AVITA PHARMACY 1029
STD782121 Texas Health Action
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Covered Entity Details
Entity Name
Texas Health Action
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD782121
Entity Address
1219 McCullough
San Antonio, TX 78212
Grant Number
1H25PS004360-02
Participating Start Date
10/1/2017
Last Recertification Date
5/15/2019
Entity Termination Date
4/1/2020
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
7/27/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Avita Pharmacy
JERRY PURCELL, CEO/PRESIDENT
(504) 905-4587
Signed By Date
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