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PHARMBLUE LLC DBA AVITA PHARMACY 1059
STD23669 LGBT Life Center
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Covered Entity Details
Entity Name
LGBT Life Center
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD23669
Entity Address
20 Settlers Landing
Hampton, VA 23669
Grant Number
5NU62PS924750-04-00
Participating Start Date
1/1/2025
Last Recertification Date
5/26/2025
Pharmacy Details
Pharmacy Name
PHARMBLUE LLC DBA AVITA PHARMACY 1059
Pharmacy Address
1226 CHESTNUT ST
PHILADELPHIA, PA 19107
Pharmacy Comments
Contract Details
Approval Date
11/16/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Stacie Walls-Beegle, CEO
(757) 640-0929 Ext: 215
Contract Pharmacy Representative
PharmBlue
Joseph Pohl, CEO
(724) 779-4720 Ext: 001
Signed By Date
10/10/2017
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