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AVITA PHARMACY 1023
STD954042 Face to Face/Sonoma County AIDS Network
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Covered Entity Details
Entity Name
Face to Face/Sonoma County AIDS Network
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD954042
Entity Address
873 2nd Street
Santa Rosa, CA 95404
Grant Number
6NU62PS924557-01-02
Participating Start Date
3/12/2021
Last Recertification Date
5/9/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1023
Pharmacy Address
PHARMEDQUEST PHARMACY SERVICES DBA AVITA
6100 REDWOOD BLVD STE A
NOVATO, CA 94945-4501
Pharmacy Comments
Contract Details
Approval Date
3/12/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Sara Brewer, Executive Director
(707) 544-1581
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
3/12/2021
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