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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD489109 MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
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Covered Entity Details
Entity Name
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES
Subdivision Name
BUREAU OF HIV and STI PROGRAMS
Type
Sexually Transmitted Diseases
340B ID
STD489109
Entity Address
MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES, HIV/STI PROGRAMS, CLIENT AND PARTNER SERVICES DIVISION
111 W. Edgewood Blvd
Suite 11
LANSING, MI 48911-5680
Grant Number
NH25PS005170
Participating Start Date
4/1/2003
Last Recertification Date
5/12/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
4/14/2023
Contract Begin Date
4/20/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tom Dunn, DHSP Operations Section Manager
(517) 335-7203
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
4/14/2023
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