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AVITA PHARMACY 1031
HV00684A Triangle Area Network
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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
AVITA PHARMACY 1031
Pharmacy Address
PHARMBLUE HOLDINGS LLC D/B/A AVITA PHARM
1495 N 7TH ST STE B
BEAUMONT, TX 77702-1345
Pharmacy Comments
Contract Details
Approval Date
4/10/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Dena Gray Hughes, CEO
(409) 832-8338 Ext: 222
Contract Pharmacy Representative
PharmBlue
Joseph Pohl, CEO
(724) 779-4720 Ext: 001
Signed By Date
4/10/2017
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