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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD18657 WYOMING VALLEY AIDS COUNCIL, INC.
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Covered Entity Details
Entity Name
WYOMING VALLEY AIDS COUNCIL, INC.
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD18657
Entity Address
1 Kim Ave
3
Tunkhannock, PA 18657
Grant Number
NH25PS005144-05-06
Participating Start Date
10/1/2019
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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