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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