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AVITA PHARMACY 1005
CH0910260 SOUTH BAY FAMILY HEALTH CARE CENTER INC
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Covered Entity Details
Entity Name
SOUTH BAY FAMILY HEALTH CARE CENTER INC
Subdivision Name
SOUTH BAY FAMILY HEALTHCARE CENTER
Type
HRSA-Funded Health Center
340B ID
CH0910260
Entity Address
23430 Hawthorne Blvd
Torrance, CA 90505-4720
Grant Number
H80CS00877
Participating Start Date
4/1/2004
Last Recertification Date
2/4/2021
Entity Termination Date
1/1/2022
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1005
Pharmacy Address
PHARMEDQUEST PHARMACY SERVICES DBA AVITA
2114 ARTESIA BLVD RM 111
REDONDO BEACH, CA 90278-3014
Pharmacy Comments
Contract Details
Approval Date
8/20/2020
Contract Begin Date
8/20/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
JANN HAMILTON LEE, CHIEF EXECUTIVE OFFICER
(310) 802-6177 Ext: 1105
Contract Pharmacy Representative
PharMedQuest
Meera Hasolkar, Director of Pharmacy Operations
(714) 364-4008
Signed By Date
8/20/2020
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