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AVITA PHARMACY 1001
CH0925360 JWCH INSTITUTE, INC.
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Covered Entity Details
Entity Name
JWCH INSTITUTE, INC.
Subdivision Name
JWCH Institute Corporate Headquarters
Type
HRSA-Funded Health Center
340B ID
CH0925360
Entity Address
5650 JILLSON ST
COMMERCE, CA 90040-1482
Grant Number
H80CS06673
Participating Start Date
9/16/2005
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
10/30/2014
Contract Begin Date
1/1/2015
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
10/30/2014
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