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AVITA PHARMACY 1029
STD79902 Southwest Viral Med
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Covered Entity Details
Entity Name
Southwest Viral Med
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD79902
Entity Address
1201 East Schuster Avenue, Building 7
El Paso, TX 79902
Grant Number
NH25PS005182
Participating Start Date
10/1/2017
Last Recertification Date
5/6/2024
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
12/31/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Avita Drugs
JERRY PURCELL, FOUNDER
(504) 905-4587
Signed By Date
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