Contract Pharmacy Details

PHARMBLUE LLC DBA AVITA PHARMACY 1059
CH04392B MANTACHIE RURAL HEALTH CARE INC

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

PHARMBLUE LLC DBA AVITA PHARMACY 1059

Pharmacy Address

1226 CHESTNUT ST
PHILADELPHIA, PA 19107

Pharmacy Comments

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

340B Drug Pricing Program Database