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PHARMBLUE LLC DBA AVITA PHARMACY 1059
HV60120 OPEN DOOR CLINIC OF GREATER ELGIN
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Covered Entity Details
Entity Name
OPEN DOOR CLINIC OF GREATER ELGIN
Subdivision Name
Type
Ryan White Part C
340B ID
HV60120
Entity Address
1665 Larkin Ave
ELGIN, IL 60123
Grant Number
H76HA01704
Participating Start Date
10/1/2004
Last Recertification Date
2/28/2022
Entity Termination Date
4/1/2023
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
10/15/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Perry Maier, Executive Director
(847) 695-1093
Contract Pharmacy Representative
PharmBlue
Joseph Pohl, CEO
(724) 779-4720 Ext: 001
Signed By Date
10/15/2014
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