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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWII28470 Life Changers Intervention Services LLC
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Covered Entity Details
Entity Name
Life Changers Intervention Services LLC
Subdivision Name
Type
Ryan White Part B
340B ID
RWII28470
Entity Address
5039 Main Street
Suite 2
Shallotte, NC 28470
Grant Number
X07HA00051
Participating Start Date
7/21/2022
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
10/15/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Beverly Stanley, CEO/Executive Director
(910) 754-7988
Contract Pharmacy Representative
PharmBlue
Joseph Pohl, CEO
(724) 779-4720 Ext: 001
Signed By Date
10/15/2014
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