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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWI10004 Exponents, Inc.
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Covered Entity Details
Entity Name
Exponents, Inc.
Subdivision Name
Type
Ryan White Part A
340B ID
RWI10004
Entity Address
17 Battery Place
8th Floor
New York, NY 10004
Grant Number
H89HA00015
Participating Start Date
1/1/2017
Last Recertification Date
2/21/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
4/6/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Regina Edwards, Executive Vice President & CFO
(212) 243-3434 Ext: 304
Contract Pharmacy Representative
PharmBlue, LLC
Joseph P. Pohl III, CEO
(724) 779-4720 Ext: 033
Signed By Date
4/6/2018
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