Contract Pharmacy Details

PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWII97403B HIV Alliance

Covered Entity Details

Entity Name

HIV Alliance

Subdivision Name

Marion County Office

Type

Ryan White Part B

340B ID

RWII97403B

Entity Address

3886 Beverly Ave. NE
Building I, Suite 6
Salem, OR 97305

Grant Number

X07HA00007

Participating Start Date

4/1/2020

Last Recertification Date

2/12/2025

Pharmacy Details

Pharmacy Name

PHARMBLUE LLC DBA AVITA PHARMACY 1059

Pharmacy Address

1226 CHESTNUT ST
PHILADELPHIA, PA 19107

Pharmacy Comments

Contract Details

Approval Date

3/6/2020

Contract Begin Date

4/1/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Renee Yandel, Executive Director
(541) 342-5088 Ext: 118

Contract Pharmacy Representative

PharmBlue
Gabriel Santry, Director of National Accounts
(724) 779-4720 Ext: 017

Signed By Date

1/15/2020

340B Drug Pricing Program Database