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AVITA PHARMACY 1040
CH046080 CENTRAL MISSISSIPPI HEALTH SERVICES, INC.
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Covered Entity Details
Entity Name
CENTRAL MISSISSIPPI HEALTH SERVICES, INC.
Subdivision Name
CENTRAL MISSISSIPPI HEALTH SERVICES, INC.
Type
HRSA-Funded Health Center
340B ID
CH046080
Entity Address
1134 Winter St
Jackson, MS 39204-2841
Grant Number
H80CS00860
Participating Start Date
7/1/1996
Last Recertification Date
3/4/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1040
Pharmacy Address
AVITA DRUGS, LLC D/B/A AVITA PHARMACY 10
6100 CORPORATE BLVD STE 250
BATON ROUGE, LA 70808
Pharmacy Comments
Contract Details
Approval Date
1/8/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
ROBERT SMITH, CEO
(601) 948-5572
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
1/8/2018
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