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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD40504 AVOL Kentucky
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Covered Entity Details
Entity Name
AVOL Kentucky
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD40504
Entity Address
1824 Hill Rise Drive
Suite 100
Lexington, KY 40504
Grant Number
NU62PS924846
Participating Start Date
1/1/2021
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
1/8/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jon M Parker, Executive Director
(859) 225-3000 Ext: 1026
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
1/8/2024
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