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AVITA PHARMACY 1028
STD328066 Two Spirit Health Services
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Covered Entity Details
Entity Name
Two Spirit Health Services
Subdivision Name
Orlando Infectious Disease Clinic
Type
Sexually Transmitted Diseases
340B ID
STD328066
Entity Address
2884 S. Osceola Avenue
Orlando, FL 32806
Grant Number
1H25PS00432-02
Participating Start Date
7/1/2018
Last Recertification Date
Entity Termination Date
1/1/2019
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
5/21/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/6/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
David Baker-Hargrove, President/Co-CEO
(321) 800-2922
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
4/11/2018
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