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AVITA PHARMACY 1024
CH09489H Venice Family Clinic
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Covered Entity Details
Entity Name
Venice Family Clinic
Subdivision Name
Venice Family Clinic - South Bay Family Health Care - OB
Type
HRSA-Funded Health Center
340B ID
CH09489H
Entity Address
323 N Prairie Ave Ste 210
Inglewood, CA 90301-4504
Grant Number
H80CS04217
Participating Start Date
12/3/2021
Last Recertification Date
2/24/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1024
Pharmacy Address
PHARMEDQUEST PHARMACY SERVICES DBA AVITA
330 E LAMBERT RD STE 120
BREA, CA 92821-4100
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
Thomas Siegmeth, acct manager
(323) 816-0525
Signed By Date
11/29/2021
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