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ACTON VALE PHARMACY
RWI93536 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
High Desert Multi-Service Ambulatory Care Center
Type
Ryan White Part A
340B ID
RWI93536
Entity Address
335 East Ave I
Lancaster, CA 93535
Grant Number
H89HA00016
Participating Start Date
1/1/2012
Last Recertification Date
2/22/2022
Entity Termination Date
4/1/2023
Pharmacy Details
Pharmacy Name
ACTON VALE PHARMACY
Pharmacy Address
THE BAIDEN GROUP INC.
3630 SMITH AVE
SUITE A
ACTON, CA 93510
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
Beryl Brooks, Administrator
(661) 471-4200
Contract Pharmacy Representative
AMIHYIA AMMA BUSUMAFI, Pharmacy Owner
(661) 269-9911
Signed By Date
1/9/2013
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