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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD788521 Maverick County Hospital District
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Covered Entity Details
Entity Name
Maverick County Hospital District
Subdivision Name
Urgent Care
Type
Sexually Transmitted Diseases
340B ID
STD788521
Entity Address
2824 N. Veterans BLVD
Suite A
Eagle Pass, TX 78852
Grant Number
NH25PS005182
Participating Start Date
1/1/2025
Last Recertification Date
5/15/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
11/13/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Nestor Bonilla, CEO
(830) 757-4961
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
10/15/2024
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