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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD01830 HealthQuarters d/b/a HealthQ
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Covered Entity Details
Entity Name
HealthQuarters d/b/a HealthQ
Subdivision Name
Haverhill Site
Type
Sexually Transmitted Diseases
340B ID
STD01830
Entity Address
215 Summer Street
Suite 16
Haverhill, MA 01830
Grant Number
NH25PS005167
Participating Start Date
4/1/2017
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
12/18/2020
Contract Begin Date
12/30/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Gabrielle Ross, Executive Director
(978) 489-4993
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
12/18/2020
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