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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD18202 Wyoming Valley AIDS Council
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Covered Entity Details
Entity Name
Wyoming Valley AIDS Council
Subdivision Name
Hazleton Clinic
Type
Sexually Transmitted Diseases
340B ID
STD18202
Entity Address
426 Airport Beltway
130
Hazleton, PA 18202
Grant Number
NH25PS005144-05-06
Participating Start Date
10/1/2023
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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