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AVITA PHARMACY 1001
CH092536S JWCH INSTITUTE, INC.
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Covered Entity Details
Entity Name
JWCH INSTITUTE, INC.
Subdivision Name
JWCH Medical Clinic @ Bell Shelter
Type
HRSA-Funded Health Center
340B ID
CH092536S
Entity Address
5600 Rickenbacker Road, Bldg. E-1
Bell, CA 90201
Grant Number
H80CS06673
Participating Start Date
1/1/2015
Last Recertification Date
2/15/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1001
Pharmacy Address
PHARMEDQUEST PHARMACY SERVICES DBA AVITA
522 S SAN PEDRO ST # 141
LOS ANGELES, CA 90013-2102
Pharmacy Comments
Contract Details
Approval Date
7/10/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/31/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
ALVARO BALLESTEROS, EXECUTIVE DIRECTOR
(323) 201-4516 Ext: 3009
Contract Pharmacy Representative
PharMedQuest
Jerry Chang, Pharmacist
(714) 364-4008 Ext: 104
Signed By Date
7/10/2018
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