Contract Pharmacy Details

PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWII65201 Spectrum Health Care

Covered Entity Details

Entity Name

Spectrum Health Care

Subdivision Name

Spectrum Health Care

Type

Ryan White Part B

340B ID

RWII65201

Entity Address

1123 WIlkes Blvd.
Suite 250
Columbia, MO 65201-4774

Grant Number

X07HA00030-27

Participating Start Date

4/1/2014

Last Recertification Date

1/28/2020

Entity Termination Date

4/1/2021

Pharmacy Details

Pharmacy Name

PHARMBLUE LLC DBA AVITA PHARMACY 1059

Pharmacy Address

1226 CHESTNUT ST
PHILADELPHIA, PA 19107

Pharmacy Comments

Contract Details

Approval Date

3/14/2014

Contract Begin Date

4/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2021
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Cale Mitchell, Executive Director
(573) 875-8687 Ext: 261

Contract Pharmacy Representative

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

Signed By Date

3/13/2014

340B Drug Pricing Program Database