Contract Pharmacy Details

PHARMBLUE LLC DBA AVITA PHARMACY 1059
FQHCLA414 Metro Health Inc

Covered Entity Details

Entity Name

Metro Health Inc

Subdivision Name

Metro Health Main Site

Type

Health Center Program Look-Alike

340B ID

FQHCLA414

Entity Address

1012 14th St NW Ste 700
Washington, DC 20005-3477

Grant Number

LALCS39530

Participating Start Date

1/1/2021

Last Recertification Date

1/30/2024

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

7/15/2021

Contract Begin Date

8/9/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2025
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Miguel McInnis, CEO
(202) 838-9271

Contract Pharmacy Representative

Avita
Chris Creamer, COO
(469) 592-2000

Signed By Date

7/15/2021