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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD06489 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
Southington Clinic - CT
Type
Sexually Transmitted Diseases
340B ID
STD06489
Entity Address
1131 West St. Building #1
Southington, CT 06489
Grant Number
6 NU62PS924521-04-02
Participating Start Date
12/28/2022
Last Recertification Date
6/4/2024
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
12/28/2022
Contract Begin Date
12/28/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jami Dybik, Director
(843) 814-5177
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
12/22/2022
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