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AVITA PHARMACY 1021
CH095380 Marin Community Clinic
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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 1021
Pharmacy Address
PHARMEDQUEST PHARMACY SERVICES DBA AVITA
1260 S ELISEO DR STE 201
GREENBRAE, CA 94904-2009
Pharmacy Comments
Contract Details
Approval Date
1/14/2021
Contract Begin Date
2/24/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/25/2022
Pharmacy closed
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
1/14/2021
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