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EVERGREEN RX INC
CHC28987-02 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
HRSA-Funded Health Center
340B ID
CHC28987-02
Entity Address
5831 Firestone Blvd., Ste E
South Gate, CA 90280-3718
Grant Number
H80CS28987
Participating Start Date
4/1/2017
Last Recertification Date
2/10/2025
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
1/23/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Yury Akopyan, CEO
(310) 730-6362
Contract Pharmacy Representative
Evergreen Rx, Inc DBA Medico Pharmacy
Afshin Azizisefat, PIC
(310) 444-9011
Signed By Date
1/23/2017
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