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PHARMBLUE LLC DBA AVITA PHARMACY 1059
FP496014 DISTRICT HEALTH DEPT NO 10
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Covered Entity Details
Entity Name
DISTRICT HEALTH DEPT NO 10
Subdivision Name
Wexford
Type
Family Planning (Title X only)
340B ID
FP496014
Entity Address
521 COBB ST
CADILLAC, MI 49601
Grant Number
FPHPA006540
Participating Start Date
1/1/1998
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
4/2/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Sheila Parker, Clinical Supervisor
(231) 236-7588
Contract Pharmacy Representative
PMQ Group, LLC dba Avita
Chris Creamer, SVP
(469) 592-2000
Signed By Date
4/2/2024
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