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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWII87110 New Mexico AIDS Services, Inc.
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Covered Entity Details
Entity Name
New Mexico AIDS Services, Inc.
Subdivision Name
Type
Ryan White Part B
340B ID
RWII87110
Entity Address
625 Truman St. NE
Albuquerque, NM 87110
Grant Number
X07HA00084
Participating Start Date
1/1/2014
Last Recertification Date
1/30/2015
Entity Termination Date
1/1/2016
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
12/11/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2016
Contacts
Covered Entity Signing Official
Kathleen Kelley, CEO
(505) 938-7100 Ext: 7114
Contract Pharmacy Representative
PharmBlue
Joseph Pohl, CEO
(724) 779-4720 Ext: 001
Signed By Date
12/9/2013
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