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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD60435 Agape Missions, NFP
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Covered Entity Details
Entity Name
Agape Missions, NFP
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD60435
Entity Address
840 Plainfield Road
Joliet, IL 60435
Grant Number
NU62PS924566
Participating Start Date
1/1/2022
Last Recertification Date
5/16/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
7/14/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jill Ann Skole, CEO
(815) 723-1548 Ext: 201
Contract Pharmacy Representative
Avita Pharmacy
Chris Creamer, COO
(630) 776-9478
Signed By Date
7/14/2022
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