Organization
PHARMBLUE LLC
Active
Organization
PHARMBLUE LLC
Active
Other names
Avita Pharmacy 1059, PharmBlue LLC, Avita
Organization subpart
No
Provider details
NPI number
Authorized official
CARL CODY COLQUITT (CHIEF FINANCIAL OFFICER)
(469) 850-6930
Entity
Organization
Contact information
Practice address
1226 CHESTNUT ST, PHILADELPHIA, PA 19107-4849
(855) 779-4720
(558) 779-4721
Mailing address
10604 COURSEY BLVD, BATON ROUGE, LA 70816-4015
(469) 592-2011
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
054.018350
IL
3336C0003X
Community/Retail Pharmacy
1495
CA
3336C0003X
Community/Retail Pharmacy
22-13036
KS
3336C0003X
Community/Retail Pharmacy
22299MS
ID
3336C0003X
Community/Retail Pharmacy
4214
IA
3336C0003X
Community/Retail Pharmacy
64001499A
IN
3336C0003X
Community/Retail Pharmacy
A9-0001259
DE
3336C0003X
Community/Retail Pharmacy
NRX0000260
DC
3336C0003X
Community/Retail Pharmacy
OSP.0006224
CO
3336C0003X
Community/Retail Pharmacy
PA1671
KY
3336C0003X
Community/Retail Pharmacy
PCN.0002541
CT
3336C0003X
Community/Retail Pharmacy
PH27097
FL
3336C0003X
Community/Retail Pharmacy
Primary
PHAO1275
AK
3336C0003X
Community/Retail Pharmacy
PHNR000016
GA
3336C0003X
Community/Retail Pharmacy
PMP854
HI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
10026562700
—
NE
05
—
102811091 0001
—
PA
05
—
1386984771
—
MN
05
—
1386984771
—
MT
05
—
1386984771
—
TN
05
—
1386984771
—
VA
05
—
1386984771
—
WA
05
—
152103
—
OH
01
—
2139860
PK
—
05
—
3096207
—
NH
05
—
48076554
—
NM
05
—
500689502
—
OR
05
—
70409100
—
MD
05
—
7P2344
—
SC
05
—
82828501
—
DC
Enumeration date
02/21/2013
Last updated
02/20/2025
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