Contract Pharmacy Details

PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD19123 Bebashi - Transition to Hope

Covered Entity Details

Entity Name

Bebashi - Transition to Hope

Subdivision Name

Type

Sexually Transmitted Diseases

340B ID

STD19123

Entity Address

1235 Spring Garden Street
Philadelphia, PA 19123

Grant Number

6 NU62PS924728-03-04

Participating Start Date

1/1/2016

Last Recertification Date

5/5/2025

Pharmacy Details

Pharmacy Name

PHARMBLUE LLC DBA AVITA PHARMACY 1059

Pharmacy Address

1226 CHESTNUT ST
PHILADELPHIA, PA 19107

Pharmacy Comments

Contract Details

Approval Date

1/11/2016

Contract Begin Date

4/1/2016

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Gary Bell, Executive Director
(215) 769-3561

Contract Pharmacy Representative

Nota Consulting Group, LLC
Fungisai Nota, 340B Program Manager
(610) 742-7763

Signed By Date

1/11/2016

340B Drug Pricing Program Database