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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWII78852 MAVERICK COUNTY HOSPITAL DISTRICT
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Covered Entity Details
Entity Name
MAVERICK COUNTY HOSPITAL DISTRICT
Subdivision Name
RYAN WHITE HIV PROGRAM
Type
Ryan White Part B
340B ID
RWII78852
Entity Address
3406 Bob Rogers Drive
STE 230
Eagle Pass, TX 78852
Grant Number
X07HA00054
Participating Start Date
10/1/2017
Last Recertification Date
2/20/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
7/26/2017
Contract Begin Date
10/1/2017
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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