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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD43812 KNO-HO-CO-ASHLAND COMMUNITY ACTION COMMISSION
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Covered Entity Details
Entity Name
KNO-HO-CO-ASHLAND COMMUNITY ACTION COMMISSION
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD43812
Entity Address
120 N 4TH ST
COSHOCTON, OH 43812
Grant Number
6NH25PS005134-05-07
Participating Start Date
10/1/2022
Last Recertification Date
5/5/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
4/17/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
KELLY CORRIGAN, ADMINISTRATOR
(740) 622-9801 Ext: 1030
Contract Pharmacy Representative
PMQ Group, LLC dba Avita
Chris Creamer, SVP
(469) 592-2000
Signed By Date
4/17/2023
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