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AVITA PHARMACY 1001
CH092536AT JWCH Institute, Inc.
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Covered Entity Details
Entity Name
JWCH Institute, Inc.
Subdivision Name
Wesley Health Centers - MLK Recuperative Care Center
Type
HRSA-Funded Health Center
340B ID
CH092536AT
Entity Address
1670 E. 120th Street, West Support BLDG #14 FL 1
Los Angeles, CA 90059-3026
Grant Number
H80CS06673
Participating Start Date
10/1/2020
Last Recertification Date
2/19/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1001
Pharmacy Address
PHARMEDQUEST PHARMACY SERVICES DBA AVITA
522 S SAN PEDRO ST # 141
LOS ANGELES, CA 90013-2102
Pharmacy Comments
Contract Details
Approval Date
7/16/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
ALVARO BALLESTEROS, EXECUTIVE DIRECTOR
(323) 201-4516 Ext: 3009
Contract Pharmacy Representative
PharMedQuest
Meera Hasolkar, Director of Pharmacy Operations
(714) 364-4008
Signed By Date
7/14/2020
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