Contract Pharmacy Details

AVITA PHARMACY 1028
RWI75204 Legacy Counseling Center Inc.

Covered Entity Details

Entity Name

Legacy Counseling Center Inc.

Subdivision Name

Dallas

Type

Ryan White Part A

340B ID

RWI75204

Entity Address

4054 McKinney Ave. Suite 102
Dallas, TX 75204

Grant Number

H89HA00014

Participating Start Date

4/1/2018

Last Recertification Date

Entity Termination Date

4/1/2019

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

1/26/2018

Contract Begin Date

4/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2019
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Melissa Grove, Executive Director
(214) 207-3953

Contract Pharmacy Representative

AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587

Signed By Date

1/10/2018

340B Drug Pricing Program Database