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AVITA PHARMACY 1060
CH04392B MANTACHIE RURAL HEALTH CARE INC
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Covered Entity Details
Entity Name
MANTACHIE RURAL HEALTH CARE INC
Subdivision Name
MANTACHIE RURAL HEALTH CARE, INC. DENTAL
Type
HRSA-Funded Health Center
340B ID
CH04392B
Entity Address
5500 Highway 363
Mantachie, MS 38855-7197
Grant Number
H80CS00096
Participating Start Date
4/1/2016
Last Recertification Date
2/24/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1060
Pharmacy Address
RX BLUE STAR SOLUTIONS, LLC DBA AVITA PH
40 PENNWOOD PL STE 200
WARRENDALE, PA 15086-6625
Pharmacy Comments
12/21/2012 address update (was 107 GEORGE RD EVANS CITY 16033); 2/23/11 UPDATED ZIP (WAS 16053)
Contract Details
Approval Date
2/10/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
PharmBlue, LLC
Joseph P. Pohl III, CEO
(724) 779-4720 Ext: 033
Signed By Date
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