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PHARMBLUE LLC DBA AVITA PHARMACY 1059
CH060190 OUTPATIENT MEDICAL CENTERS, INC.
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Covered Entity Details
Entity Name
OUTPATIENT MEDICAL CENTERS, INC.
Subdivision Name
Type
HRSA-Funded Health Center
340B ID
CH060190
Entity Address
1640 Breazeale Springs Street
Natchitoches, LA 71457
Grant Number
H80CS00513
Participating Start Date
4/1/2006
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
10/10/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tamara D. Johnson, CEO
(318) 357-2055
Contract Pharmacy Representative
PharmBlue
Joseph Pohl, CEO
(724) 779-4720 Ext: 001
Signed By Date
10/10/2016
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