Contract Pharmacy Details

AVITA PHARMACY 1001
CH092536U JWCH INSTITUTE, INC.

Covered Entity Details

Entity Name

JWCH INSTITUTE, INC.

Subdivision Name

Wesley Health Centers (Vermont)

Type

HRSA-Funded Health Center

340B ID

CH092536U

Entity Address

954 N. Vermont Ave.
LOS ANGELES, CA 90029-3529

Grant Number

H80CS06673

Participating Start Date

1/1/2015

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

7/1/2016

Contract Begin Date

10/1/2016

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

7/1/2016

340B Drug Pricing Program Database