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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWI00053 LGBT Life Center
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Covered Entity Details
Entity Name
LGBT Life Center
Subdivision Name
Type
Ryan White Part A
340B ID
RWI00053
Entity Address
248 W. 24th St.
Norfolk, VA 23517
Grant Number
H89HA00053
Participating Start Date
4/1/2013
Last Recertification Date
2/21/2022
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
4/2/2013
Contract Begin Date
4/5/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Stacie Walls-Beegle, Executive Director
(757) 640-0929 Ext: 215
Contract Pharmacy Representative
PharmBlue
Joseph Pohl, CEO
(724) 779-4720 Ext: 001
Signed By Date
4/2/2013
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