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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD53212 Holton Street Clinic, Inc
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Covered Entity Details
Entity Name
Holton Street Clinic, Inc
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD53212
Entity Address
3251 N. HOLTON ST.
MILWAUKEE, WI 53212-2126
Grant Number
1U52PS005148
Participating Start Date
1/1/2008
Last Recertification Date
5/7/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
7/9/2021
Contract Begin Date
8/3/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David Wenten, Executive Director
(414) 264-8800
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
7/9/2021
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