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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWI85034 Chicanos Por La Causa Inc
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Covered Entity Details
Entity Name
Chicanos Por La Causa Inc
Subdivision Name
LUCES
Type
Ryan White Part A
340B ID
RWI85034
Entity Address
1112 E. Buckeye Rd
Phoenix, AZ 85034
Grant Number
H89HA11478-17-00
Participating Start Date
10/1/2018
Last Recertification Date
2/25/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
8/6/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Pedro Antonio Cons, Executive Vice President
(602) 257-0700
Contract Pharmacy Representative
PharmBlue, LLC
Joseph P. Pohl III, CEO
(724) 779-4720 Ext: 033
Signed By Date
7/2/2018
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