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PHARMBLUE LLC DBA AVITA PHARMACY 1059
FP024023 BROCKTON FAMILY PLANNING
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Covered Entity Details
Entity Name
BROCKTON FAMILY PLANNING
Subdivision Name
Type
Family Planning (Title X only)
340B ID
FP024023
Entity Address
111 TORREY ST
BROCKTON, MA 02301
Grant Number
FPHPA016029
Participating Start Date
1/1/1998
Last Recertification Date
5/28/2019
Entity Termination Date
10/1/2019
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Emily Gold, Director of Reproductive Health Services
(508) 274-6541
Contract Pharmacy Representative
PharmBlue, LLC
Joseph P. Pohl III, CEO
(724) 779-4720 Ext: 033
Signed By Date
10/15/2018
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