Contract Pharmacy Details

AVITA PHARMACY 1040
CH095380 Marin Community Clinic

Covered Entity Details

Entity Name

Marin Community Clinic

Subdivision Name

Marin Community Clinic - Larkspur

Type

HRSA-Funded Health Center

340B ID

CH095380

Entity Address

5 Bon Air Road, Suite 117
Larkspur, CA 94939-1138

Grant Number

H80CS00343

Participating Start Date

10/1/2001

Last Recertification Date

2/13/2025

Pharmacy Details

Pharmacy Name

AVITA PHARMACY 1040

Pharmacy Address

AVITA DRUGS, LLC D/B/A AVITA PHARMACY 10
6100 CORPORATE BLVD STE 250
BATON ROUGE, LA 70808

Pharmacy Comments

Contract Details

Approval Date

10/15/2020

Contract Begin Date

1/1/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

8/8/2023
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Mitesh Popat, CEO
(415) 755-2581

Contract Pharmacy Representative

PharMedQuest
Meera Hasolkar, Director of Pharmacy Operations
(714) 364-4008

Signed By Date

10/15/2020

340B Drug Pricing Program Database