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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD974021 HIV Alliance
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Covered Entity Details
Entity Name
HIV Alliance
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD974021
Entity Address
1195 A City View Street
Eugene, OR 97402
Grant Number
NH25PS005149-05-05
Participating Start Date
4/1/2018
Last Recertification Date
5/5/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
7/12/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Renee Yandel, Executive Director
(541) 342-5088 Ext: 118
Contract Pharmacy Representative
PharMedQuest
Meera Hasolkar, Director of Pharmacy Operations
(714) 364-4008
Signed By Date
7/12/2021
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