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AVITA PHARMACY 1005
CH091026F 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
SBFHC-Carson
Type
HRSA-Funded Health Center
340B ID
CH091026F
Entity Address
270 East 223rd Street
Carson, CA 90745
Grant Number
H80CS00877
Participating Start Date
4/1/2014
Last Recertification Date
2/7/2021
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
8/23/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Diana Concannon, Vice President
(310) 802-6177 Ext: 1106
Contract Pharmacy Representative
South Bay Family Health Care
Bertha Becerra, QA/QI Director
(310) 802-6177 Ext: 1116
Signed By Date
8/23/2020
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