Contract Pharmacy Details

PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWII779010 Crossroads Virology

Covered Entity Details

Entity Name

Crossroads Virology

Subdivision Name

Type

Ryan White Part B

340B ID

RWII779010

Entity Address

1403 Victoria Station Dr.
Victoria, TX 77901

Grant Number

X07HA00054

Participating Start Date

7/20/2020

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

10/24/2019

Contract Begin Date

1/1/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2020
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Thomas A Kaspar, Medical Director
(830) 832-6956

Contract Pharmacy Representative

PharmBlue, LLC
Joseph P. Pohl III, CEO
(724) 779-4720 Ext: 033

Signed By Date

10/24/2019

340B Drug Pricing Program Database