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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWI55404 African American Aids Task Force
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Covered Entity Details
Entity Name
African American Aids Task Force
Subdivision Name
Type
Ryan White Part A
340B ID
RWI55404
Entity Address
122 W. Franklin Avenue
518
Minneapolis, MN 55404
Grant Number
H89HA00050
Participating Start Date
7/1/2016
Last Recertification Date
2/27/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
7/5/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Gwendolyn Velez, Executive Director
(612) 823-2052
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
7/5/2023
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