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AVITA PHARMACY 1040
CH092536AR JWCH Institute, Inc.
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Covered Entity Details
Entity Name
JWCH Institute, Inc.
Subdivision Name
JWCH PATH CLINIC
Type
HRSA-Funded Health Center
340B ID
CH092536AR
Entity Address
340 N. MADISON
LOS ANGELES, CA 90004-3504
Grant Number
H80CS06673
Participating Start Date
10/1/2020
Last Recertification Date
2/17/2022
Entity Termination Date
4/1/2023
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
4/1/2023
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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