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AVITA PHARMACY 1029
STD770571 AIDS Foundation Houston, Inc.
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Covered Entity Details
Entity Name
AIDS Foundation Houston, Inc.
Subdivision Name
Crofoot
Type
Sexually Transmitted Diseases
340B ID
STD770571
Entity Address
3701 Kirby Drive
Suite 1230
Houston, TX 77098
Grant Number
5 NU65PS004736
Participating Start Date
10/1/2017
Last Recertification Date
5/12/2020
Entity Termination Date
1/1/2021
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
1/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Avita Drugs
Jerry Purcell, Executive Vice President
(504) 905-4587
Signed By Date
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