Contract Pharmacy Details

PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWI60120 OPEN DOOR CLINIC OF GREATER ELGIN

Covered Entity Details

Entity Name

OPEN DOOR CLINIC OF GREATER ELGIN

Subdivision Name

Type

Ryan White Part A

340B ID

RWI60120

Entity Address

1665 Larkin Ave
ELGIN, IL 60123

Grant Number

H89HA00008

Participating Start Date

4/1/2012

Last Recertification Date

2/18/2025

Pharmacy Details

Pharmacy Name

PHARMBLUE LLC DBA AVITA PHARMACY 1059

Pharmacy Address

1226 CHESTNUT ST
PHILADELPHIA, PA 19107

Pharmacy Comments

Contract Details

Approval Date

10/15/2014

Contract Begin Date

1/1/2015

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Perry Maier, Executive Director
(847) 695-1093

Contract Pharmacy Representative

PharmBlue
Joseph Pohl, CEO
(724) 779-4720 Ext: 001

Signed By Date

10/15/2014

340B Drug Pricing Program Database