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AVITA PHARMACY 1001
CH092536AX JWCH Institute, Inc.
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Covered Entity Details
Entity Name
JWCH Institute, Inc.
Subdivision Name
JWCH PATH Clinic
Type
HRSA-Funded Health Center
340B ID
CH092536AX
Entity Address
320 N Madison Ave Ste A
Los Angeles, CA 90004-3791
Grant Number
H80CS06673
Participating Start Date
7/1/2022
Last Recertification Date
2/19/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1001
Pharmacy Address
PHARMEDQUEST PHARMACY SERVICES DBA AVITA
522 S SAN PEDRO ST # 141
LOS ANGELES, CA 90013-2102
Pharmacy Comments
Contract Details
Approval Date
4/18/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
ALVARO BALLESTEROS, EXECUTIVE DIRECTOR
(323) 201-4516 Ext: 3009
Contract Pharmacy Representative
Long's Drugs
Ashley Ellis, Corporate Counsel
(803) 254-5884 Ext: 42309
Signed By Date
4/14/2022
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