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MADISON HOME PHARMACY CORP
CH090850 AMPLA HEALTH
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Covered Entity Details
Entity Name
AMPLA HEALTH
Subdivision Name
Ampla Health Lindhurst Medical, Dental, & Xpress Care
Type
HRSA-Funded Health Center
340B ID
CH090850
Entity Address
4941 Olivehurst Ave
Olivehurst, CA 95961-4225
Grant Number
H80CS00765
Participating Start Date
1/1/1998
Last Recertification Date
2/14/2025
Pharmacy Details
Pharmacy Name
MADISON HOME PHARMACY CORP
Pharmacy Address
DBA MADISON HOME PHARMACY
1811 W KATELLA AVE SUITE 229
ANAHEIM, CA 92804
Pharmacy Comments
Contract Details
Approval Date
4/13/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/15/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Benjamin H. Flores, President & CEO
(530) 674-4261 Ext: 1155
Contract Pharmacy Representative
Nota Consulting Group, LLC
Fungisai Nota, 340B Program Manager
(610) 742-7763
Signed By Date
4/13/2018
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