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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD199736 Anna C. Shipley State Service Center
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Covered Entity Details
Entity Name
Anna C. Shipley State Service Center
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD199736
Entity Address
350 Virginia Ave.
Seaford, DE 19973
Grant Number
NH25PS005156
Participating Start Date
7/1/2024
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
5/8/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Attillio J Zarrella, Administrator, STI Program
(302) 744-1063
Contract Pharmacy Representative
PMQ Group, LLC dba Avita
Chris Creamer, SVP
(469) 592-2000
Signed By Date
4/1/2024
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