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PHARMBLUE LLC DBA AVITA PHARMACY 1059
CHC26572-00 MyCare Heatlh Center
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Covered Entity Details
Entity Name
MyCare Heatlh Center
Subdivision Name
Mount Clemens
Type
HRSA-Funded Health Center
340B ID
CHC26572-00
Entity Address
18 Market St STE C
Mount Clemens, MI 48043-7403
Grant Number
H80CS26572
Participating Start Date
7/1/2014
Last Recertification Date
2/26/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
7/18/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/8/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Darlene Vasi, CEO
(248) 689-1340
Contract Pharmacy Representative
PharmBlue
Gabriel Santry, Director of National Accounts
(724) 779-4720 Ext: 017
Signed By Date
7/18/2014
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