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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWIIR76302 Nortex Regional Planning Commission
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Covered Entity Details
Entity Name
Nortex Regional Planning Commission
Subdivision Name
Type
Ryan White Part B ADAP Rebate Option
340B ID
RWIIR76302
Entity Address
4309 Jackboro Highway, Suite 200
Wichita Falls, TX 76302
Grant Number
X07HA00054
Participating Start Date
4/1/2019
Last Recertification Date
2/12/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
3/13/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Dennis Wilde, Executive Director
(940) 322-5281 Ext: 9403225281
Contract Pharmacy Representative
PharmBlue, LLC
Joseph P. Pohl III, CEO
(724) 779-4720 Ext: 033
Signed By Date
2/11/2019
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