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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWII78667 Community Action, Inc. of Central Texas
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Covered Entity Details
Entity Name
Community Action, Inc. of Central Texas
Subdivision Name
Type
Ryan White Part B
340B ID
RWII78667
Entity Address
215 S. Reimer Avenue Suite 140
San Marcos, TX 78666
Grant Number
X07HA00054
Participating Start Date
7/1/2019
Last Recertification Date
2/14/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
6/7/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Douglas Mudd, EXECUTIVE DIRECTOR
(512) 392-1161 Ext: 332
Contract Pharmacy Representative
PharmBlue, LLC
Joseph P. Pohl III, CEO
(724) 779-4720 Ext: 033
Signed By Date
5/3/2019
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