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AVITA PHARMACY 1040
STD33712 Empath Health, Inc.
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Covered Entity Details
Entity Name
Empath Health, Inc.
Subdivision Name
AIDS Service Association of Pinellas dba EPIC
Type
Sexually Transmitted Diseases
340B ID
STD33712
Entity Address
3050 1st Ave S
St. Petersburg, FL 33712
Grant Number
1NU62PS924687-1-00
Participating Start Date
4/1/2018
Last Recertification Date
5/9/2024
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
4/2/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/21/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mitchel Morel, CFO
(727) 523-3339
Contract Pharmacy Representative
Avita Drugs
KEITH FOX, CFO
(225) 236-1540
Signed By Date
4/2/2018
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