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AVITA PHARMACY 1026
STD85012 Spectrum Medical Care Center
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Covered Entity Details
Entity Name
Spectrum Medical Care Center
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD85012
Entity Address
52 E Monterey Way
Suite A
Phoenix, AZ 85012
Grant Number
1 NU62PS924550-01-00
Participating Start Date
1/1/2019
Last Recertification Date
5/5/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1026
Pharmacy Address
PHARMBLUE ARIZONA LLC
1260 S CAMPBELL AVE STE 1152
GREEN VALLEY, AZ 85614-0504
Pharmacy Comments
Contract Details
Approval Date
7/15/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Thanes J Vanig, Chief Medical Officer
(602) 604-9500
Contract Pharmacy Representative
Avita
Keith Fox, Senior VP National Accounts
(225) 315-8181
Signed By Date
7/15/2024
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