Contract Pharmacy Details

870 SOUTHERN DRUG CORP
RWI10004 Exponents, Inc.

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

870 SOUTHERN DRUG CORP

Pharmacy Address

D/B/A AVITA PHARMACY 1064
924 MYRTLE AVE
BROOKLYN, NY 11206

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

340B Drug Pricing Program Database