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EVERGREEN RX INC
FQHCLA322A COMPLETE CARE COMMUNITY HEALTH CENTER, INC.
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Covered Entity Details
Entity Name
COMPLETE CARE COMMUNITY HEALTH CENTER, INC.
Subdivision Name
Complete Care Health Center - South Gate
Type
Health Center Program Look-Alike
340B ID
FQHCLA322A
Entity Address
5831 Firestone Blvd., Ste E
South Gate, CA 90280-3718
Grant Number
LALCS00153
Participating Start Date
10/1/2015
Last Recertification Date
2/14/2017
Entity Termination Date
4/1/2018
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
10/2/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Yury Akopyan, CEO
(562) 806-7545
Contract Pharmacy Representative
Evergreen Rx, Inc DBA Medico Pharmacy
Afshin Azizisefat, PIC
(310) 444-9011
Signed By Date
10/2/2015
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