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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD235101 LGBT Life Center
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Covered Entity Details
Entity Name
LGBT Life Center
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD235101
Entity Address
5360 Robin Hood Rd
Suite 200
Norfolk, VA 23513
Grant Number
NU62PS924552
Participating Start Date
4/1/2017
Last Recertification Date
6/4/2024
Entity Termination Date
7/1/2024
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
2/2/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/7/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
PharmBlue
Joseph Pohl, CEO
(724) 779-4720 Ext: 001
Signed By Date
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