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AVITA PHARMACY 1022
CH09538B MARIN COMMUNITY CLINIC
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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 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
9/30/2019
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
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