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AVITA PHARMACY 1001
CH092536AG JWCH Institute, Inc.
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Covered Entity Details
Entity Name
JWCH Institute, Inc.
Subdivision Name
Wesley Health Centers -- Fedde International Studies Academy
Type
HRSA-Funded Health Center
340B ID
CH092536AG
Entity Address
21409 Elaine Ave
Hawaiian Gardens, CA 90716-1025
Grant Number
H80CS06673
Participating Start Date
7/1/2018
Last Recertification Date
2/17/2022
Entity Termination Date
4/1/2023
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
4/1/2023
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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