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AVITA PHARMACY 1014
CH092536AN JWCH Institute, Inc.
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Covered Entity Details
Entity Name
JWCH Institute, Inc.
Subdivision Name
Wesley Health Centers- Palmdale Central
Type
HRSA-Funded Health Center
340B ID
CH092536AN
Entity Address
2151 E Palmdale Blvd
Palmdale, CA 93550-4037
Grant Number
H80CS06673
Participating Start Date
5/2/2019
Last Recertification Date
2/19/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1014
Pharmacy Address
PHARMEDQUEST PHARMACY SERVICES DBA AVITA
45104 10TH ST W STE A
LANCASTER, CA 93534-2310
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
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
1/15/2020
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