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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD061141 Latino Community Services, Inc.
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Covered Entity Details
Entity Name
Latino Community Services, Inc.
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD061141
Entity Address
28 Grand Street 2nd FL
Hartford, CT 06106
Grant Number
1NH25PS005155 01
Participating Start Date
7/1/2017
Last Recertification Date
5/6/2024
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
4/24/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
PharmBlue
Joseph Pohl, CEO
(724) 779-4720 Ext: 001
Signed By Date
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