Covered Entity Details

CH10253K INTERNATIONAL COMMUNITY HEALTH SERVICES (Active) - information as of 5/5/2025 11:52:28 PM

Main Details

Name

INTERNATIONAL COMMUNITY HEALTH SERVICES

Subdivision Name

Mobile Medical Clinic

Type

HRSA-Funded Health Center

Site ID

BPS-H80-038078

340B ID

CH10253K

Grant Number

H80CS00437

Additional Details

Current Program Status

Active

Registration Date

10/2/2024

Participating Start Date

1/1/2025

Participating Approval Date

12/4/2024

Last Recertification Date

2/12/2025

Contacts

Authorizing Official

ICHS
Kelli Nomura, CEO
(206) 788-3659

Primary Contact

ICHS
Ju Hui Lee, Pharmacy Director
(206) 788-3756

Addresses

Street Address

720 8th Ave S
Seattle, WA 98104-3032

Billing Address

International Community Health Services
PO Box 3007
Seattle, WA 98114

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
WA	1021911	1902983109

Shipping Addresses

Shipping Address 1

ICHS Holly Park Medical & Dental Clinic
3815 S Othello St
Seattle, WA 98118

Shipping Address 2

International Community Health Services
720 8th Ave S.
Seattle, WA 98104

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH102530	Active	BPS-H80-004690	INTERNATIONAL COMMUNITY HEALTH SERVICES	INTERNATIONAL COMMUNITY HEALTH SERVICES	720 8TH AVENUE SOUTH	SEATTLE	WA
CH10253A	Active	BPS-H80-005436	INTERNATIONAL COMMUNITY HEALTH SERVICES	ICHS - HOLLY PARK MEDICAL & DENTAL CLINIC	3815 S OTHELLO ST	SEATTLE	WA
CH10253B	Active	BPS-H80-018526	INTERNATIONAL COMMUNITY HEALTH SERVICES	Seattle World School (SWS)	1700 E. Union Street	Seattle	WA
CH10253C	Active	BPS-H80-013852	INTERNATIONAL COMMUNITY HEALTH SERVICES	ICHS Bellevue Medical and Dental Clinic	1050 140TH AVE NE	BELLEVUE	WA
CH10253D	Active	BPS-H80-014064	INTERNATIONAL COMMUNITY HEALTH SERVICES	ICHS Shoreline Medical and Dental Clinic	16549 Aurora Ave N	Shoreline	WA
CH10253E	Active	BPS-H80-035594	International Community Health Services	Highland Middle School	15027 NE Bel Red Rd	Bellevue	WA
CH10253F	Terminated	BPS-H80-020914	International Community Health Services	ICHS Vision Clinic	718 8th Avenue South	Seattle	WA
CH10253G	Active	BPS-H80-024836	International Community Health Services	Legacy House Clinic	803 S Lane St	Seattle	WA
CH10253H	Active	BPS-H80-010575	International Community Health Services	ACRS	3639 M L King Jr Way S	Seattle	WA
CH10253J	Active	BPS-H80-019301	International Community Health Services	ICHS Mobile Dental Clinic	720 8th Avenue South	Seattle	WA
CH10253K	Active	BPS-H80-038078	INTERNATIONAL COMMUNITY HEALTH SERVICES	Mobile Medical Clinic	720 8th Ave S	Seattle	WA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH102530	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	07/01/2025
CH102530	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	07/01/2025
CH102530	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	07/01/2025
CH102530	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	07/01/2025
CH102530	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	07/01/2025
CH102530	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	07/01/2025
CH102530	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	07/01/2025
CH102530	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	07/01/2025
CH102530	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	07/01/2025
CH102530	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	07/01/2025
CH102530	GENOA HEALTHCARE LLC	11000 LAKE CITY WAY NE STE 421		SEATTLE	WA	98125	07/01/2025
CH102530	GENOA HEALTHCARE LLC	325 W. GOWE STREET	SUITE 110	KENT	WA	98032	07/01/2025
CH102530	GENOA HEALTHCARE LLC	2704 I STREET NE		AUBURN	WA	98002	07/01/2025
CH102530	GENOA HEALTHCARE LLC	1600 EAST OLIVE STREET	BLDG D	SEATTLE	WA	98122	07/01/2025
CH102530	KP PHARMACY AND MEDICAL SUPPLIES, LLC	KP PHARMACY & MEDICAL SUPPLIES LLC	7101 MARTIN LUTHER KING JR WAY S STE 101B	SEATTLE	WA	98118-3591	11/16/2022	03/22/2023
CH102530	LUKE'S PHARMACY	611 MAYNARD AVE S		SEATTLE	WA	98104-2920	11/16/2022	07/11/2023
CH102530	NGUYEN PHARMACY AND GIFTS, INC	NGUYEN'S PHARMACY AND GIFTS	2120 RAINIER AVE S STE A	SEATTLE	WA	98144	11/16/2022	07/01/2024
CH102530	NGUYENS PHARMACY AND GIFTS	INC	NGUYEN, JOHN D C, PRESIDENT 1221 S. MAIN ST STE 103	SEATTLE	WA	98144	11/16/2022	01/08/2024
CH102530	OPTUM INFUSION SERVICES 305, LLC	15529 COLLEGE BLVD.		LENEXA	KS	66219-1351	07/01/2025
CH102530	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	07/01/2025
CH102530	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	07/01/2025
CH102530	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	07/01/2025
CH102530	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	07/01/2025
CH102530	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	07/01/2025
CH102530	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	07/01/2025
CH102530	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	07/01/2025
CH102530	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	07/01/2025
CH102530	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	07/01/2025
CH102530	OTHELLO STATION PHARMACY	SALAAM HEALTH PLLC	4219 S OTHELLO ST # 105F	SEATTLE	WA	98118-3892	11/16/2022
CH102530	SY PHARMACY AND WELLNESS	3828 S GRAHAM ST UNIT B		SEATTLE	WA	98118-3158	01/01/2024
CH102530	WALGREEN CO	DBA; WALGREENS #10995	3716 S 144TH STREET	TUKWILA	WA	98168	04/01/2014
CH102530	WALGREEN CO.	DBA: WALGREENS # 03632	2400 S. JACKSON ST.	SEATTLE	WA	98144	04/01/2014
CH102530	WALGREEN CO.	DBA: WALGREENS # 03733	7707 SE 27TH STREET	MERCER ISLAND	WA	98040	04/01/2014
CH102530	WALGREEN CO.	DBA: WALGREENS # 03840	14656 AMBAUM BLVD SW	BURIEN	WA	98166	04/01/2014
CH102530	WALGREEN CO.	DBA: WALGREENS # 04627	275 RAINIER AVENUE S	RENTON	WA	98057	04/01/2014
CH102530	WALGREEN CO.	DBA: WALGREENS # 04898	6330 35TH AVE. SW	SEATTLE	WA	98126	04/01/2014
CH102530	WALGREEN CO.	DBA: WALGREENS # 05950	4412 RAINIER AVE S	SEATTLE	WA	98118	04/01/2014
CH102530	WALGREEN CO.	DBA: WALGREENS # 06194	222 PIKE STREET	SEATTLE	WA	98101-3635	04/01/2014
CH102530	WALGREEN CO.	DBA: WALGREENS # 06259	9456 16TH AVE SW	SEATTLE	WA	98106-2824	04/01/2014
CH102530	WALGREEN CO.	DBA: WALGREENS # 07355	3011 NE SUNSET BLVD	RENTON	WA	98056	04/01/2014
CH102530	WALGREEN CO.	DBA: WALGREENS # 09373	17524 AURORA AVENUE NORTH	SHORELINE	WA	98133-4813	04/01/2014
CH102530	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16403	1409 11TH AVE.	SEATTLE	WA	98122	04/01/2014
CH102530	WALGREEN CO.	DBA: WALGREENS # 03662	647 140TH AVENUE NE	BELLEVUE	WA	98005	04/01/2014
CH102530	WALGREEN CO.	DBA: WALGREENS #10553	15585 NE 24TH ST.	BELLEVUE	WA	98007-3836	04/01/2014
CH102530	WALGREEN CO.	DBA: WALGREENS # 03788	14510 AURORA AVE N	SHORELINE	WA	98133-6525	07/01/2015
CH102530	WALGREEN CO.	DBA: WALGREENS # 04759	17518 15TH AVE NE	SHORELINE	WA	98155	07/01/2015	02/28/2019
CH102530	WALGREEN CO.	DBA: WALGREENS # 04157	859 NE NORTHGATE WAY	SEATTLE	WA	98125	01/01/2020
CH102530	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	04/01/2014	07/10/2015
CH102530	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	10/01/2016	10/01/2021
CH102530	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	10/01/2016
CH102530	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	10/01/2016

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification		2/12/2025 11:15:17 AM	2/12/2025 11:15 AM
Details	State	Update		Approved	Active	1/1/2025 12:01 AM
Addresses	Shipping Address	Delete	New Registration	ICHS Holly Park Medical & Dental Clinic 3815 S Othello St Seattle, WA 98118		12/4/2024 10:41 AM
Addresses	Shipping Address	Delete	New Registration	International Community Health Services 720 8th Ave S. Seattle, WA 98104		12/4/2024 10:41 AM
Addresses	Billing Address	Insert	New Registration		International Community Health Services PO Box 3007 Seattle, WA 98114	12/4/2024 10:41 AM
Addresses	Shipping Address	Insert	New Registration		ICHS Holly Park Medical & Dental Clinic 3815 S Othello St Seattle, WA 98118	12/4/2024 10:41 AM
Addresses	Shipping Address	Insert	New Registration		International Community Health Services 720 8th Ave S. Seattle, WA 98104	12/4/2024 10:41 AM
Contacts	Signed By	Insert	New Registration		Nomura, Kelli CEO ICHS 2067883659	12/4/2024 10:41 AM
Details	340B ID	Update	New Registration		CH10253K	12/4/2024 10:41 AM
Dates	Participating Approval Date	Update	New Registration		12/4/2024 10:41:54 AM	12/4/2024 10:41 AM
Details	State	Update	New Registration	Pending	Approved	12/4/2024 10:41 AM
Dates	Signed By Date	Update	New Registration		10/14/2024 11:21:26 AM	12/4/2024 10:41 AM
Dates	Start Date	Update	New Registration		1/1/2025 12:00:00 AM	12/4/2024 10:41 AM
Addresses	Billing Address	Insert	New Registration		International Community Health Services PO Box 3007 Seattle, WA 98114	10/14/2024 11:21 AM
Addresses	Shipping Address	Insert	New Registration		ICHS Holly Park Medical & Dental Clinic 3815 S Othello St Seattle, WA 98118	10/14/2024 11:21 AM
Addresses	Shipping Address	Insert	New Registration		International Community Health Services 720 8th Ave S. Seattle, WA 98104	10/14/2024 11:21 AM
Addresses	Main Address	Insert	New Registration		720 8th Ave S Seattle, WA 98104-3032	10/2/2024 11:10 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/2/2024 11:10 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1021911	10/2/2024 11:10 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		WA	10/2/2024 11:10 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1902983109	10/2/2024 11:10 AM
Medicaid Billing	NPI: State	Insert	New Registration		WA	10/2/2024 11:10 AM
Contacts	Primary Contact	Insert	New Registration		Lee, Ju Hui Pharmacy Director ICHS 2067883756	10/2/2024 11:10 AM
Contacts	Authorizing Official	Insert	New Registration		Nomura, Kelli CEO ICHS 2067883659	10/2/2024 11:10 AM
Details	Assistance Received From Date	Insert	New Registration			10/2/2024 11:10 AM
Details	Assistance Received To Date	Insert	New Registration			10/2/2024 11:10 AM
Details	Last Recertification Date	Insert	New Registration			10/2/2024 11:10 AM
Details	Grant Number	Insert	New Registration		H80CS00437	10/2/2024 11:10 AM
Details	340B ID	Insert	New Registration			10/2/2024 11:10 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/2/2024 11:10 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/2/2024 11:10 AM
Details	Medicare Provider Number	Insert	New Registration			10/2/2024 11:10 AM
Details	Entity Name	Insert	New Registration		INTERNATIONAL COMMUNITY HEALTH SERVICES	10/2/2024 11:10 AM
Details	NOFO Number	Insert	New Registration			10/2/2024 11:10 AM
Details	Program Code	Insert	New Registration		CH	10/2/2024 11:10 AM
Details	Entity Subname	Insert	New Registration		Mobile Medical Clinic	10/2/2024 11:10 AM
Dates	Participating Approval Date	Insert	New Registration			10/2/2024 11:10 AM
Details	State	Insert	New Registration		Pending	10/2/2024 11:10 AM
Dates	Registration Date	Insert	New Registration		10/2/2024 11:10:38 AM	10/2/2024 11:10 AM
Dates	Signed By Date	Insert	New Registration			10/2/2024 11:10 AM
Dates	Start Date	Insert	New Registration			10/2/2024 11:10 AM
Terminations	Termination Comments	Insert	New Registration			10/2/2024 11:10 AM
Terminations	Termination Date	Insert	New Registration			10/2/2024 11:10 AM
Terminations	Termination Effective Date	Insert	New Registration			10/2/2024 11:10 AM
Terminations	Termination Reason	Insert	New Registration			10/2/2024 11:10 AM

340B Drug Pricing Program Database