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PHARMBLUE LLC DBA AVITA PHARMACY 1059
RWI60422 Proactive Community Services
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Covered Entity Details
Entity Name
Proactive Community Services
Subdivision Name
Type
Ryan White Part A
340B ID
RWI60422
Entity Address
19740 Governors Highway
Suite 118
Flossmoor, IL 60422
Grant Number
H89HA00008
Participating Start Date
1/1/2023
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
2/10/2023
Contract Begin Date
2/13/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Eula Burge, CEO/Executive Director
(708) 248-6166
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
2/10/2023
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