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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD606161 Alliance Care 360
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Covered Entity Details
Entity Name
Alliance Care 360
Subdivision Name
Medical Mobile Unit
Type
Sexually Transmitted Diseases
340B ID
STD606161
Entity Address
2929 S Wabash ave
STE 202
202
Chicago, IL 60616
Grant Number
NU62PS924733
Participating Start Date
8/30/2021
Last Recertification Date
5/8/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
8/3/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ariq Cabbler, Executive Director/Chief Executive Officer
(312) 808-1044 Ext: 101
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
8/3/2022
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