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AVITA PHARMACY 1028
RWII39202 My Brother's Keeper, Inc.
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Covered Entity Details
Entity Name
My Brother's Keeper, Inc.
Subdivision Name
Open Arms Healthcare Center
Type
Ryan White Part B
340B ID
RWII39202
Entity Address
805 East River Place
Jackson, MS 39202
Grant Number
5X07HA00036-33-00
Participating Start Date
10/1/2017
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1028
Pharmacy Address
340B PARTNERS PHARMACY-DALLAS LLC DBA AV
750 FORT WORTH AVE STE H100
DALLAS, TX 75208-1811
Pharmacy Comments
Contract Details
Approval Date
10/16/2017
Contract Begin Date
11/6/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
June Gipson, CEO
(769) 216-2455
Contract Pharmacy Representative
Avita Drugs
Mark Roth, Account Manager
(504) 908-5932
Signed By Date
10/16/2017
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