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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD23607 Minority AIDS Support Services, Inc.
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Covered Entity Details
Entity Name
Minority AIDS Support Services, Inc.
Subdivision Name
NPN - STD Clinic
Type
Sexually Transmitted Diseases
340B ID
STD23607
Entity Address
247 28th Street
Ste. 100
Newport News, VA 23607
Grant Number
H25PS005137
Participating Start Date
10/1/2018
Last Recertification Date
5/12/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
10/13/2021
Contract Begin Date
10/26/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Gwendolyn R Ellis-Wilson, Director of Operations
(757) 247-1879 Ext: 207
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
10/13/2021
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