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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWI606162 Alliance Care 360
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Covered Entity Details
Entity Name
Alliance Care 360
Subdivision Name
Type
Ryan White Part A
340B ID
RWI606162
Entity Address
2929 S Wabash Avenue,
Suite
202
Chicago, IL 60616-3243
Grant Number
H89HA00008
Participating Start Date
7/1/2018
Last Recertification Date
2/3/2024
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
8/3/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Ariq Cabbler, Executive Director/Chief Executive Officer
(312) 808-1044 Ext: 101
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
8/3/2022
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