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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWII02657 Provincetown AIDS Support Group d.b.a. AIDS Support Group of Cape Cod
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Covered Entity Details
Entity Name
Provincetown AIDS Support Group d.b.a. AIDS Support Group of Cape Cod
Subdivision Name
Type
Ryan White Part B
340B ID
RWII02657
Entity Address
96-98 Bradford Street
Provincetown, MA 02657
Grant Number
X07HA00082
Participating Start Date
4/1/2015
Last Recertification Date
2/28/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
1/22/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Erik Buford, Sales Director
(617) 835-5022
Signed By Date
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