Contract Pharmacy Details

AVITA PHARMACY 1025
CH09538B MARIN COMMUNITY CLINIC

Covered Entity Details

Entity Name

MARIN COMMUNITY CLINIC

Subdivision Name

Marin Community Clinic - San Rafael

Type

HRSA-Funded Health Center

340B ID

CH09538B

Entity Address

3110 KERNER BLVD
SAN RAFAEL, CA 94901

Grant Number

H80CS00343

Participating Start Date

1/1/2010

Last Recertification Date

2/13/2025

Pharmacy Details

Pharmacy Name

AVITA PHARMACY 1025

Pharmacy Address

PHARMEDQUEST PHARMACY SERVICES DBA AVITA
3020 SATURN ST STE 100
BREA, CA 92821

Pharmacy Comments

Contract Details

Approval Date

4/3/2019

Contract Begin Date

7/1/2019

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

8/8/2023
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Mitesh Popat, CEO
(415) 755-2581

Contract Pharmacy Representative

PharMedQuest
Meera Hasolkar, Director of Pharmacy Operations
(714) 364-4008

Signed By Date

4/3/2019

340B Drug Pricing Program Database