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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD85034 Chicanos Por La Causa Inc.
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Covered Entity Details
Entity Name
Chicanos Por La Causa Inc.
Subdivision Name
LUCES
Type
Sexually Transmitted Diseases
340B ID
STD85034
Entity Address
1112 E. Buckeye Rd
Phoenix, AZ 85034
Grant Number
NU62PS924818
Participating Start Date
10/1/2019
Last Recertification Date
6/2/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
9/4/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Pedro Antonio Cons, Executive Vice President
(602) 257-0700
Contract Pharmacy Representative
PharmBlue, LLC
Joseph P. Pohl III, CEO
(724) 779-4720 Ext: 033
Signed By Date
7/10/2019
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