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AVITA PHARMACY 1040
CH092536AY JWCH Institute, Inc.
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Covered Entity Details
Entity Name
JWCH Institute, Inc.
Subdivision Name
Wesley Health Centers - San Julian Oasis
Type
HRSA-Funded Health Center
340B ID
CH092536AY
Entity Address
628 San Julian St
Los Angeles, CA 90014-2412
Grant Number
H80CS06673
Participating Start Date
4/1/2023
Last Recertification Date
2/19/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1040
Pharmacy Address
AVITA DRUGS, LLC D/B/A AVITA PHARMACY 10
6100 CORPORATE BLVD STE 250
BATON ROUGE, LA 70808
Pharmacy Comments
Contract Details
Approval Date
1/17/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
ALVARO BALLESTEROS, EXECUTIVE DIRECTOR
(323) 201-4516 Ext: 3009
Contract Pharmacy Representative
PharMedQuest
Jerry Chang, Pharmacist
(714) 364-4008 Ext: 104
Signed By Date
1/17/2023
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