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AVITA PHARMACY 1031
RWII76905 Shannon Business Services
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Covered Entity Details
Entity Name
Shannon Business Services
Subdivision Name
Shannon Supportive Health Services
Type
Ryan White Part B
340B ID
RWII76905
Entity Address
402 W. 26th Street
San Angelo, TX 76903
Grant Number
X07HA00054
Participating Start Date
10/1/2018
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1031
Pharmacy Address
PHARMBLUE HOLDINGS LLC D/B/A AVITA PHARM
1495 N 7TH ST STE B
BEAUMONT, TX 77702-1345
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
2/14/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Pam Bradshaw, COO/CNO
(325) 653-6741
Contract Pharmacy Representative
PharmBlue, LLC
Joseph P. Pohl III, CEO
(724) 779-4720 Ext: 033
Signed By Date
7/13/2018
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