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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWI06106 Advancing Connecticut Together, Inc.
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Covered Entity Details
Entity Name
Advancing Connecticut Together, Inc.
Subdivision Name
Main Office
Type
Ryan White Part A
340B ID
RWI06106
Entity Address
110 Bartholomew Avenue, Suite 3050
Hartford, CT 06106
Grant Number
H89HA00044
Participating Start Date
10/1/2016
Last Recertification Date
2/7/2024
Entity Termination Date
7/1/2024
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
1/18/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
John Merz, CEO
(860) 247-2437 Ext: 314
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
1/18/2022
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