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PHARMBLUE LLC DBA AVITA PHARMACY 1059
CH022070 ANTHONY L JORDAN HEALTH CORP
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Covered Entity Details
Entity Name
ANTHONY L JORDAN HEALTH CORP
Subdivision Name
Main Site
Type
HRSA-Funded Health Center
340B ID
CH022070
Entity Address
82 Holland St
Rochester, NY 14605-2131
Grant Number
H80CS21582
Participating Start Date
10/1/2011
Last Recertification Date
2/10/2025
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
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/28/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jonathan Clune, CFO
(585) 423-2813
Contract Pharmacy Representative
Avita Pharmacy
Ryan Boyle, Chief Privacy Officer and Regulatory Attorney Counsel
(225) 236-1538
Signed By Date
7/15/2021
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