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AVITA PHARMACY 1028
STD782122 BEAT AIDS Coalition Trust
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Covered Entity Details
Entity Name
BEAT AIDS Coalition Trust
Subdivision Name
Your Choice Clinic
Type
Sexually Transmitted Diseases
340B ID
STD782122
Entity Address
230 E Fredericksburg Rd
San Antonio, TX 78212
Grant Number
NU65PS923645
Participating Start Date
7/1/2018
Last Recertification Date
5/28/2024
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
MICHELE DURHAM, EXECUTIVE DIRECTOR
(210) 212-2266 Ext: 102
Contract Pharmacy Representative
Avita Pharmacy Solutions
Chip House, Account Executive
(512) 595-4036
Signed By Date
4/13/2018
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