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OLIVE BRANCH PHARMACY
FQHCLA308A Universal Community Health Center
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Covered Entity Details
Entity Name
Universal Community Health Center
Subdivision Name
Universal Community Health Center - San Pedro St.
Type
Health Center Program Look-Alike
340B ID
FQHCLA308A
Entity Address
2801 S. San Pedro St.
Los Angeles, CA 90011
Grant Number
H80CS30722
Participating Start Date
10/1/2016
Last Recertification Date
1/30/2019
Entity Termination Date
7/1/2019
Pharmacy Details
Pharmacy Name
OLIVE BRANCH PHARMACY
Pharmacy Address
2811 S. SAN PEDRO ST
LOS ANGELES, CA 90011
Pharmacy Comments
Contract Details
Approval Date
7/7/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2017
Agreement registered in error
Contacts
Covered Entity Signing Official
Agustin Jaime Lara, CEO
(323) 620-2596
Contract Pharmacy Representative
Olive Branch Pharmacy
redda alhousayni, pharmacist
(213) 536-4888
Signed By Date
7/7/2016
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