Contract Pharmacy Details

PHARMBLUE LLC DBA AVITA PHARMACY 1059
HV060210 VALLEY AIDS COUNCIL

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

PHARMBLUE LLC DBA AVITA PHARMACY 1059

Pharmacy Address

1226 CHESTNUT ST
PHILADELPHIA, PA 19107

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

340B Drug Pricing Program Database