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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD1980812 Lotus Healthcare Group LLC
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Covered Entity Details
Entity Name
Lotus Healthcare Group LLC
Subdivision Name
Lotus Recovery Centers of Prices Corner LLC
Type
Sexually Transmitted Diseases
340B ID
STD1980812
Entity Address
1812 Newport Gap Pike
Wilmington, DE 19808
Grant Number
NH25PS005156
Participating Start Date
7/1/2024
Last Recertification Date
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
5/1/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael Mesveskas, Chief Operating Officer
(856) 220-8647
Contract Pharmacy Representative
PMQ Group, LLC dba Avita
Chris Creamer, SVP
(469) 592-2000
Signed By Date
4/5/2024
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