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AVITA PHARMACY 1028
STD78721 Center for Health Empowerment
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Covered Entity Details
Entity Name
Center for Health Empowerment
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD78721
Entity Address
2312 Western Trails Blvd
Ste 103
Austin, TX 78745
Grant Number
NH25PS005182
Participating Start Date
7/1/2018
Last Recertification Date
5/5/2025
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
5/2/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Valerie Agee, Chief Operations Officer
(512) 840-1273
Contract Pharmacy Representative
Avita Drugs
JERRY PURCELL, EVP
(504) 905-4587
Signed By Date
4/13/2018
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