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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWI38104 Friends For Life
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Covered Entity Details
Entity Name
Friends For Life
Subdivision Name
Type
Ryan White Part A
340B ID
RWI38104
Entity Address
1548 Poplar Ave
Memphis, TN 38104
Grant Number
H89HA11464
Participating Start Date
7/1/2018
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
4/20/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Diane Duke, Executive Director
(901) 333-8240
Contract Pharmacy Representative
PharmBlue, LLC
Joseph P. Pohl III, CEO
(724) 779-4720 Ext: 033
Signed By Date
4/14/2018
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