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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWII79601 Dignity Health Management Center, Inc.
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Covered Entity Details
Entity Name
Dignity Health Management Center, Inc.
Subdivision Name
Type
Ryan White Part B
340B ID
RWII79601
Entity Address
402 Butternut St.
Abilene, TX 79602
Grant Number
X07HA00054
Participating Start Date
4/28/2022
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
4/28/2022
Contract Begin Date
4/28/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
James Wagstaff, Executive Director
(917) 570-8015
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
4/28/2022
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