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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD554042 African American AIDS Task Force
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Covered Entity Details
Entity Name
African American AIDS Task Force
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD554042
Entity Address
122 W. Franklin Avenue
Minneapolis, MN 55404
Grant Number
NH25PS005172
Participating Start Date
1/1/2020
Last Recertification Date
5/8/2024
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
7/13/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Gwendolyn Velez, Executive Director
(612) 823-2052
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
7/13/2022
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