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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWI44102 Nueva Luz Urban Resource Center
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Covered Entity Details
Entity Name
Nueva Luz Urban Resource Center
Subdivision Name
Type
Ryan White Part A
340B ID
RWI44102
Entity Address
6600 Detroit Avenue
Cleveland, OH 44102
Grant Number
H89HA23812
Participating Start Date
7/1/2016
Last Recertification Date
2/14/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
4/15/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Max Rodas, Chief Executive Officer
(216) 857-0558
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
4/15/2022
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