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AVITA PHARMACY 1026
HV060210 VALLEY AIDS COUNCIL
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Covered Entity Details
Entity Name
VALLEY AIDS COUNCIL
Subdivision Name
Type
Ryan White Part C
340B ID
HV060210
Entity Address
2306 Camelot Plaza Circle
HARLINGEN, TX 78550
Grant Number
H76HA00131
Participating Start Date
1/1/1998
Last Recertification Date
2/27/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1026
Pharmacy Address
PHARMBLUE ARIZONA LLC
1260 S CAMPBELL AVE STE 1152
GREEN VALLEY, AZ 85614-0504
Pharmacy Comments
Contract Details
Approval Date
10/14/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/15/2019
Agreement registered in error
Contacts
Covered Entity Signing Official
Wally Cantu, Executive Director
(956) 428-2653
Contract Pharmacy Representative
PharmBlue, LLC
Joseph P. Pohl III, CEO
(724) 779-4720 Ext: 033
Signed By Date
10/14/2019
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