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EVERGREEN RX INC
FQHCLA409A AMH COMPREHENSIVE MEDICAL CENTERS
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Covered Entity Details
Entity Name
AMH COMPREHENSIVE MEDICAL CENTERS
Subdivision Name
AMH Comprehensive Medical Centers - Maywood
Type
Health Center Program Look-Alike
340B ID
FQHCLA409A
Entity Address
6017 Atlantic Blvd
Maywood, CA 90270-3118
Grant Number
LALCS33896
Participating Start Date
7/1/2021
Last Recertification Date
3/10/2025
Pharmacy Details
Pharmacy Name
EVERGREEN RX INC
Pharmacy Address
DBA MEDICO PHARMACY
11779 SANTA MONICA BLVD
LOS ANGELES, CA 90025
Pharmacy Comments
Contract Details
Approval Date
4/28/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jennelyn Argame, CEO
(213) 429-5264
Contract Pharmacy Representative
Evergreen Rx, Inc DBA Medico Pharmacy
Afshin Azizisefat, PIC
(310) 444-9011
Signed By Date
4/22/2020
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