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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD49601 District Health Department #10
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Covered Entity Details
Entity Name
District Health Department #10
Subdivision Name
Cadillac location
Type
Sexually Transmitted Diseases
340B ID
STD49601
Entity Address
521 Cobb Street
Cadillac, MI 49601
Grant Number
NH25PS005170
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
4/3/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tom Dunn, DHSP Operations Section Manager
(517) 335-7203
Contract Pharmacy Representative
PMQ Group, LLC dba Avita
Chris Creamer, SVP
(469) 592-2000
Signed By Date
4/3/2024
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