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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWII56304 Rural AIDS Action Network
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Covered Entity Details
Entity Name
Rural AIDS Action Network
Subdivision Name
Type
Ryan White Part B
340B ID
RWII56304
Entity Address
300 E St Germain Street
Ste 220
St Cloud, MN 56304
Grant Number
X07HA00043-30
Participating Start Date
7/1/2016
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
5/3/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
PharmBlue
Joseph Pohl, CEO
(724) 779-4720 Ext: 001
Signed By Date
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