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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWII60606 AIDS Foundation of Chicago
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Covered Entity Details
Entity Name
AIDS Foundation of Chicago
Subdivision Name
Type
Ryan White Part B
340B ID
RWII60606
Entity Address
200 W. Monroe St
STE 1150
Chicago, IL 60606
Grant Number
X07HA00013
Participating Start Date
1/1/2018
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
10/2/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John Peller, President & CEO
(312) 334-0921
Contract Pharmacy Representative
PharmBlue, LLC
Joseph P. Pohl III, CEO
(724) 779-4720 Ext: 033
Signed By Date
10/2/2019
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