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PHARMBLUE LLC DBA AVITA PHARMACY 1059
CH04900K ROBESON HEALTH CARE CORP
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Covered Entity Details
Entity Name
ROBESON HEALTH CARE CORP
Subdivision Name
Montgomery Health Center
Type
HRSA-Funded Health Center
340B ID
CH04900K
Entity Address
103 COTTON CREEK RD
STAR, NC 27356-7954
Grant Number
H80CS00107
Participating Start Date
1/1/2013
Last Recertification Date
2/9/2022
Entity Termination Date
4/1/2023
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
10/14/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Thomas E. Manynor II, Deputy President and CEO
(910) 521-2900 Ext: 104
Contract Pharmacy Representative
PharmBlue
Joseph Pohl, CEO
(724) 779-4720 Ext: 001
Signed By Date
10/14/2013
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