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REVAN RX
RWI891041 John Phoenix APRN PLLC
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Covered Entity Details
Entity Name
John Phoenix APRN PLLC
Subdivision Name
Huntridge Family Clinic/CAN Community Health
Type
Ryan White Part A
340B ID
RWI891041
Entity Address
1820 E. Sahara Ave
Suite 201
Las Vegas, NV 89104
Grant Number
H89HA06900
Participating Start Date
7/1/2022
Last Recertification Date
1/31/2023
Entity Termination Date
1/1/2024
Pharmacy Details
Pharmacy Name
REVAN RX
Pharmacy Address
REVAN INC
5601 NW 72ND ST STE 142
WARR ACRES, OK 73132-5923
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
John Phoenix, Chief Clinical Officer
(702) 979-1111
Contract Pharmacy Representative
Elite Analytics Group, Inc
Rex Green, CEO
(469) 899-2293
Signed By Date
7/15/2020
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