Contract Pharmacy Details

AVITA PHARMACY 1022
CH095380 Marin Community Clinic

Covered Entity Details

Entity Name

Marin Community Clinic

Subdivision Name

Marin Community Clinic - Larkspur

Type

HRSA-Funded Health Center

340B ID

CH095380

Entity Address

5 Bon Air Road, Suite 117
Larkspur, CA 94939-1138

Grant Number

H80CS00343

Participating Start Date

10/1/2001

Last Recertification Date

2/13/2025

Pharmacy Details

Pharmacy Name

AVITA PHARMACY 1022

Pharmacy Address

PHARMEDQUEST PHARMACY SERVICES DBA AVITA
3110 KERNER BLVD STE A
SAN RAFAEL, CA 94901-5411

Pharmacy Comments

Contract Details

Approval Date

7/10/2019

Contract Begin Date

10/1/2019

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

7/10/2019

340B Drug Pricing Program Database