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PHARMBLUE LLC DBA AVITA PHARMACY 1059
CH04901M EAST GEORGIA HEALTHCARE CENTER, INC.
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Covered Entity Details
Entity Name
EAST GEORGIA HEALTHCARE CENTER, INC.
Subdivision Name
Statesboro Pediatrics
Type
HRSA-Funded Health Center
340B ID
CH04901M
Entity Address
1570 Brampton Ave
Statesboro, GA 30458-5102
Grant Number
H80CS00512
Participating Start Date
10/1/2009
Last Recertification Date
1/27/2017
Entity Termination Date
4/1/2017
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
4/17/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Contacts
Covered Entity Signing Official
JENNIE WREN DENMARK, CEO
(478) 237-6262 Ext: 107
Contract Pharmacy Representative
PharmBlue
Joseph Pohl, CEO
(724) 779-4720 Ext: 001
Signed By Date
4/17/2013
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