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PHARMBLUE LLC DBA AVITA PHARMACY 1059
HV00729 Health Equity Alliance (HEAL)
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Covered Entity Details
Entity Name
Health Equity Alliance (HEAL)
Subdivision Name
Type
Ryan White Part C
340B ID
HV00729
Entity Address
5 Long Lane
Suite 1
Ellsworth, ME 04605
Grant Number
H76HA00729
Participating Start Date
4/1/2017
Last Recertification Date
2/11/2025
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
7/9/2021
Contract Begin Date
9/8/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Robbie Lorenzo, Accountant
(207) 990-3626
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
7/9/2021
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