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AVITA PHARMACY 1009
CH09882G CHILDREN'S CLINIC 'SERVING CHILDREN AND THEIR FAMILIES' THE
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Covered Entity Details
Entity Name
CHILDREN'S CLINIC 'SERVING CHILDREN AND THEIR FAMILIES' THE
Subdivision Name
The Children's Clinic at International Elementary School
Type
HRSA-Funded Health Center
340B ID
CH09882G
Entity Address
700 LOCUST AVE
LONG BEACH, CA 90813-4317
Grant Number
H80CS00264
Participating Start Date
4/1/2013
Last Recertification Date
2/19/2019
Entity Termination Date
4/1/2020
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
4/1/2020
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
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