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AVITA PHARMACY 1026
CH096030 Redwood Coast Medical Services Inc
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Covered Entity Details
Entity Name
Redwood Coast Medical Services Inc
Subdivision Name
REDWOOD COAST MEDICAL SERVICES
Type
HRSA-Funded Health Center
340B ID
CH096030
Entity Address
46900 Ocean Dr
Gualala, CA 95445-8353
Grant Number
H80CS00575
Participating Start Date
4/16/2019
Last Recertification Date
2/13/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1026
Pharmacy Address
PHARMBLUE ARIZONA LLC
1260 S CAMPBELL AVE STE 1152
GREEN VALLEY, AZ 85614-0504
Pharmacy Comments
Contract Details
Approval Date
4/3/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
DIANE AGEE, CEO
(707) 884-9135
Contract Pharmacy Representative
PharmBlue
Gabriel Santry, Director of National Accounts
(724) 779-4720 Ext: 017
Signed By Date
4/3/2017
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