Contract Pharmacy Details

AVITA PHARMACY 1009
CH09882J CHILDREN'S CLINIC 'SERVING CHILDREN AND THEIR FAMILIES' THE

Covered Entity Details

Entity Name

CHILDREN'S CLINIC 'SERVING CHILDREN AND THEIR FAMILIES' THE

Subdivision Name

The Children's Clinic Family Health Center in Central Long Beach

Type

HRSA-Funded Health Center

340B ID

CH09882J

Entity Address

2360 Pacific Avenue
Long Beach, CA 90806-3051

Grant Number

H80CS00264

Participating Start Date

4/1/2013

Last Recertification Date

2/16/2024

Entity Termination Date

4/1/2025

Pharmacy Details

Pharmacy Name

AVITA PHARMACY 1009

Pharmacy Address

PHARMEDQUEST PHARMACY SERVICES DBA AVITA
17660 LAKEWOOD BLVD
BELLFLOWER, CA 90706-6410

Pharmacy Comments

Contract Details

Approval Date

1/11/2018

Contract Begin Date

4/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2025
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Elisa Nicholas, Chief Executive Officer
(562) 264-3551 Ext: 5622643985

Contract Pharmacy Representative

PharMedQuest Pharmacy Services
Sam Badianat, Director of Program Management
(714) 364-1422 Ext: 104

Signed By Date

1/11/2018

340B Drug Pricing Program Database