Contract Pharmacy Details

PHARMBLUE LLC DBA AVITA PHARMACY 1059
HV00684A Triangle Area Network

Covered Entity Details

Entity Name

Triangle Area Network

Subdivision Name

Type

Ryan White Part C

340B ID

HV00684A

Entity Address

1495 N. 7TH ST
BEAUMONT, TX 77702

Grant Number

H76HA00684

Participating Start Date

4/1/2011

Last Recertification Date

1/31/2017

Entity Termination Date

1/1/2018

Pharmacy Details

Pharmacy Name

PHARMBLUE LLC DBA AVITA PHARMACY 1059

Pharmacy Address

1226 CHESTNUT ST
PHILADELPHIA, PA 19107

Pharmacy Comments

Contract Details

Approval Date

7/8/2013

Contract Begin Date

10/1/2013

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/1/2018
Covered Entity Terminated

Contacts

Covered Entity Signing Official

jennifer scarborough, exec director
(409) 832-8338

Contract Pharmacy Representative

Megan Russell, Director of Regulatory Affairs
(412) 726-7732

Signed By Date

7/8/2013

340B Drug Pricing Program Database