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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWII22902 AIDS/HIV Services Group
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Covered Entity Details
Entity Name
AIDS/HIV Services Group
Subdivision Name
Type
Ryan White Part B
340B ID
RWII22902
Entity Address
315 Tenth St NE
Charlottesville, VA 22902
Grant Number
T2-VA
Participating Start Date
10/1/2013
Last Recertification Date
3/10/2016
Entity Termination Date
4/1/2016
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
9/30/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2016
Contacts
Covered Entity Signing Official
Peter DeMartino, Chief Executive Officer
(434) 964-7421
Contract Pharmacy Representative
PharmBlue
Joseph Pohl, CEO
(724) 779-4720 Ext: 001
Signed By Date
9/9/2013
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