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H H HUMPHREY COMPRE HLTH CTR
RWI90059 Los Angeles County, Department of Health Services
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Covered Entity Details
Entity Name
Los Angeles County, Department of Health Services
Subdivision Name
Martin Luther King, Jr. Outpatient Center
Type
Ryan White Part A
340B ID
RWI90059
Entity Address
1670 East 120th Street
Los Angeles, CA 90059
Grant Number
H89HA90059
Participating Start Date
1/1/2012
Last Recertification Date
2/22/2022
Entity Termination Date
4/1/2023
Pharmacy Details
Pharmacy Name
H H HUMPHREY COMPRE HLTH CTR
Pharmacy Address
COUNTY OF LOS ANGELES
5850 S MAIN ST ATTN PHARMACY
LOS ANGELES, CA 90003
Pharmacy Comments
Contract Details
Approval Date
2/20/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Nadrine Balady-Bouziane, Pharm.D.
(747) 210-3059
Contract Pharmacy Representative
Amy Gutierrez, Chief Pharmacy Officer, Los Angeles County Department of Health Services
(213) 240-7717
Signed By Date
1/9/2013
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