Contract Pharmacy Details

PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWI37206 Street Works, Inc

Covered Entity Details

Entity Name

Street Works, Inc

Subdivision Name

Type

Ryan White Part A

340B ID

RWI37206

Entity Address

1326 Rosa L. Parks Blvd. Ste. B
Nashville, TN 37208

Grant Number

H89HA11433

Participating Start Date

1/1/2014

Last Recertification Date

2/10/2025

Pharmacy Details

Pharmacy Name

PHARMBLUE LLC DBA AVITA PHARMACY 1059

Pharmacy Address

1226 CHESTNUT ST
PHILADELPHIA, PA 19107

Pharmacy Comments

Contract Details

Approval Date

12/17/2013

Contract Begin Date

1/1/2014

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Ron E. Crowder, Chief Executive Officer
(615) 259-7676 Ext: 1068

Contract Pharmacy Representative

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

Signed By Date

12/16/2013

340B Drug Pricing Program Database