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AVITA PHARMACY 1001
CH092536R JWCH INSTITUTE, INC.
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Covered Entity Details
Entity Name
JWCH INSTITUTE, INC.
Subdivision Name
JWCH Medical Clinic @ Simone Hotel
Type
HRSA-Funded Health Center
340B ID
CH092536R
Entity Address
520 San Julian St
Los Angeles, CA 90013-1513
Grant Number
H80CS06673
Participating Start Date
1/1/2015
Last Recertification Date
2/21/2024
Entity Termination Date
4/1/2025
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
4/1/2025
Covered Entity Terminated
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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