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AVITA PHARMACY 1005
CH09489E Venice Family Clinic
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Covered Entity Details
Entity Name
Venice Family Clinic
Subdivision Name
Venice Family Clinic - Carole Keen Carson Wellness Center
Type
HRSA-Funded Health Center
340B ID
CH09489E
Entity Address
270 E 223rd St
Carson, CA 90745-3804
Grant Number
H80CS04217
Participating Start Date
12/3/2021
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
11/30/2021
Contract Begin Date
12/7/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/31/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
ELIZABETH BENSON FORER, EXECUTIVE DIRECTOR
(310) 664-7901
Contract Pharmacy Representative
Avita Pharmacy
Thomas Siegmeth, actt manager
(323) 816-0525
Signed By Date
11/29/2021
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