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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD185033 Wyoming Valley AIDS Council
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Covered Entity Details
Entity Name
Wyoming Valley AIDS Council
Subdivision Name
Scranton Clinic
Type
Sexually Transmitted Diseases
340B ID
STD185033
Entity Address
201 Franklin Avenue
3rd Floor
Scranton, PA 18503
Grant Number
NH25PS005144
Participating Start Date
4/1/2024
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
10/1/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
KEN J ZULA, EXECUTIVE DIRECTOR
(570) 823-5808 Ext: 302
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
10/1/2024
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