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AVITA PHARMACY 1040
CH092536R JWCH INSTITUTE, INC.
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Covered Entity Details
Entity Name
JWCH INSTITUTE, INC.
Subdivision Name
JWCH Medical Clinic @ Simone Hotel
Type
HRSA-Funded Health Center
340B ID
CH092536R
Entity Address
520 San Julian St
Los Angeles, CA 90013-1513
Grant Number
H80CS06673
Participating Start Date
1/1/2015
Last Recertification Date
2/21/2024
Entity Termination Date
4/1/2025
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
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
ALVARO BALLESTEROS, EXECUTIVE DIRECTOR
(323) 201-4516 Ext: 3009
Contract Pharmacy Representative
Long's Drugs
Ashley Ellis, Corporate Counsel
(803) 254-5884 Ext: 42309
Signed By Date
10/15/2020
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