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AVITA PHARMACY 1002
CH092536AD JWCH Institute, Inc.
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Covered Entity Details
Entity Name
JWCH Institute, Inc.
Subdivision Name
Wesley Health Centers -- Michael Antonovich Dental Clinic
Type
HRSA-Funded Health Center
340B ID
CH092536AD
Entity Address
1845 N. Fair Oaks Ave. Suite 1101
Pasadena, CA 91103-1620
Grant Number
H80CS06673
Participating Start Date
7/1/2018
Last Recertification Date
2/19/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1002
Pharmacy Address
PHARMEDQUEST PHARMACY SERVICES DBA AVITA
954 N VERMONT AVE # 132
LOS ANGELES, CA 90029-3529
Pharmacy Comments
Contract Details
Approval Date
10/4/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
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
10/4/2019
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