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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD48624 Central Michigan District Health Department
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Covered Entity Details
Entity Name
Central Michigan District Health Department
Subdivision Name
Gladwin location
Type
Sexually Transmitted Diseases
340B ID
STD48624
Entity Address
103 N. Bowery Avenue
Gladwin, MI 48624
Grant Number
NH25PS005170
Participating Start Date
1/1/2021
Last Recertification Date
5/7/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
4/15/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jaclyn Badger, Health Promotion Director
(989) 773-5921 Ext: 1628
Contract Pharmacy Representative
PMQ Group, LLC dba Avita
Chris Creamer, SVP
(469) 592-2000
Signed By Date
4/15/2024
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