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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWII76541 United Way of the Greater Tri-County Area
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Covered Entity Details
Entity Name
United Way of the Greater Tri-County Area
Subdivision Name
Type
Ryan White Part B
340B ID
RWII76541
Entity Address
208 W. Ave A
Killeen, TX 76541
Grant Number
X07HA00054
Participating Start Date
7/1/2024
Last Recertification Date
3/7/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
8/27/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Aaron Montemayor, Executive Director
(254) 634-0660
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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