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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD084011 South Jersey AIDS Alliance
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Covered Entity Details
Entity Name
South Jersey AIDS Alliance
Subdivision Name
Oasis
Type
Sexually Transmitted Diseases
340B ID
STD084011
Entity Address
32 S. Tennessee Avenue
Atlantic City, NJ 08401
Grant Number
NH25PS005174
Participating Start Date
1/1/2019
Last Recertification Date
5/6/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
7/13/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Babette J Richter, ARCH Nurse Team Leader
(609) 572-1929
Contract Pharmacy Representative
PMQ Group, LLC dba Avita
Chris Creamer, SVP
(469) 592-2000
Signed By Date
7/13/2023
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