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AVITA PHARMACY 1005
CH094890 VENICE FAMILY CLINIC
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Covered Entity Details
Entity Name
VENICE FAMILY CLINIC
Subdivision Name
VENICE FAMILY CLINIC
Type
HRSA-Funded Health Center
340B ID
CH094890
Entity Address
604 Rose Ave
Venice, CA 90291-2767
Grant Number
H80CS04217
Participating Start Date
10/1/1997
Last Recertification Date
2/14/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1005
Pharmacy Address
PHARMEDQUEST PHARMACY SERVICES DBA AVITA
2114 ARTESIA BLVD RM 111
REDONDO BEACH, CA 90278-3014
Pharmacy Comments
Contract Details
Approval Date
10/11/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/31/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
ELIZABETH BENSON FORER, EXECUTIVE DIRECTOR
(310) 664-7901
Contract Pharmacy Representative
Venice Family Clinic
Sharon Ng, Director of Pharmacy
(310) 664-7735
Signed By Date
10/11/2021
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