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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWII02657B AIDS Support Group of Cape Cod, Inc.
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Covered Entity Details
Entity Name
AIDS Support Group of Cape Cod, Inc.
Subdivision Name
Type
Ryan White Part B
340B ID
RWII02657B
Entity Address
116 Bernard E St Jean
East Falmouth, MA 02536
Grant Number
X07HA00082
Participating Start Date
7/1/2020
Last Recertification Date
2/28/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
5/13/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Paul E Goddu, CFO
(508) 487-9445
Contract Pharmacy Representative
PharmBlue, LLC
Joseph P. Pohl III, CEO
(724) 779-4720 Ext: 033
Signed By Date
4/1/2020
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