Contract Pharmacy Details

PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWII11788 Long Island Association for AIDS Care, Inc.

Covered Entity Details

Entity Name

Long Island Association for AIDS Care, Inc.

Subdivision Name

Type

Ryan White Part B

340B ID

RWII11788

Entity Address

60 Adams Avenue
Hauppauge, NY 11788

Grant Number

X08HA16847

Participating Start Date

1/1/2014

Last Recertification Date

2/1/2017

Entity Termination Date

4/1/2018

Pharmacy Details

Pharmacy Name

PHARMBLUE LLC DBA AVITA PHARMACY 1059

Pharmacy Address

1226 CHESTNUT ST
PHILADELPHIA, PA 19107

Pharmacy Comments

Contract Details

Approval Date

12/16/2013

Contract Begin Date

1/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2018
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Catherine Hart, Chief Operating Officer
(631) 385-2451

Contract Pharmacy Representative

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

Signed By Date

12/12/2013

340B Drug Pricing Program Database