Contract Pharmacy Details

PHARMBLUE LLC DBA AVITA PHARMACY 1059
HV00726 Rural AIDS Action Network

Covered Entity Details

Entity Name

Rural AIDS Action Network

Subdivision Name

Type

Ryan White Part C

340B ID

HV00726

Entity Address

300 East Saint Germain Street
Suite 220
St Cloud, MN 56304

Grant Number

H76HA00726

Participating Start Date

1/1/2014

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

2/12/2014

Contract Begin Date

2/12/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2016
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Christopher Bernard, Business Manager
(320) 257-3036

Contract Pharmacy Representative

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

Signed By Date

12/20/2013

340B Drug Pricing Program Database