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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWI60613 Center on Halsted
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Covered Entity Details
Entity Name
Center on Halsted
Subdivision Name
Center on Halsted
Type
Ryan White Part A
340B ID
RWI60613
Entity Address
3656 North Halsted Street
Chicago, IL 60613
Grant Number
H89HA00008
Participating Start Date
7/1/2022
Last Recertification Date
2/25/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
7/7/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Modesto Valle, Chief Executive Officer
(773) 472-6469 Ext: 250
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
7/7/2022
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