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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWI23669A LGBT Life Center
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Covered Entity Details
Entity Name
LGBT Life Center
Subdivision Name
Type
Ryan White Part A
340B ID
RWI23669A
Entity Address
20 Settlers Landing Road
Hampton, VA 23669
Grant Number
H89HA00053
Participating Start Date
1/1/2024
Last Recertification Date
2/21/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
8/13/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Stacie Walls-Beegle, CEO
(757) 640-0929 Ext: 215
Contract Pharmacy Representative
PharmBlue, LLC
Joseph P. Pohl III, CEO
(724) 779-4720 Ext: 033
Signed By Date
7/12/2018
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