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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD198088 Winder Laird Porter State Service Center
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Covered Entity Details
Entity Name
Winder Laird Porter State Service Center
Subdivision Name
Porter SSC
Type
Sexually Transmitted Diseases
340B ID
STD198088
Entity Address
509 W. 8TH ST
WILMINGTON, DE 19801
Grant Number
NH25PS005156
Participating Start Date
1/1/2000
Last Recertification Date
5/5/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
4/13/2021
Contract Begin Date
4/29/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/26/2023
Agreement registered in error
Contacts
Covered Entity Signing Official
Theo D Hudson, STD Program Director
(302) 744-1063
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
4/13/2021
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