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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD581024811 FARGO CASS PUBLIC HEALTH
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Covered Entity Details
Entity Name
FARGO CASS PUBLIC HEALTH
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD581024811
Entity Address
1240 25th Street South
FARGO, ND 58103
Grant Number
NH25PS005181
Participating Start Date
1/1/2005
Last Recertification Date
5/9/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
12/21/2022
Contract Begin Date
12/27/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Desi H Fleming, Director
(701) 241-1380
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
12/21/2022
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