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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD1980813 Heritage Medical Associates PA
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Covered Entity Details
Entity Name
Heritage Medical Associates PA
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD1980813
Entity Address
2601 Annand Dr.
Suite 4
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
John Fenice, Owner
(302) 650-0239
Contract Pharmacy Representative
PMQ Group, LLC dba Avita
Chris Creamer, SVP
(469) 592-2000
Signed By Date
4/8/2024
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