Covered Entity Details

CH06273AM MAINLINE HEALTH SYSTEMS INC (Approved) - information as of 6/7/2025 4:39:24 AM

Main Details

Name

MAINLINE HEALTH SYSTEMS INC

Subdivision Name

Dermott School Clinic

Type

HRSA-Funded Health Center

Site ID

BPS-H80-040001

340B ID

CH06273AM

Grant Number

H80CS00638

Additional Details

Current Program Status

Approved

Registration Date

4/1/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/4/2025

Last Recertification Date

Contacts

Authorizing Official

Mainline Health Systems
GARY ALLAN NICHOLS, Executive Director
(870) 538-5414

Primary Contact

Mainline Health Systems
Courtney Keller, PharmD
(870) 538-5414

Addresses

Street Address

525 E Speedway St
Dermott, AR 71638-2322

Billing Address

Mainline Health Systems, Inc.
342 Hwy 425 S
Monticello, AR 71655

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
AR	217430749	1477004471

Shipping Addresses

Same as Street Address

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
CH062730	Active	BPS-H80-000881	MAINLINE HEALTH SYSTEMS INC	MAINLINE HEALTH SYSTEM, INC.	233 NORTH MAIN STREET	PORTLAND	AR
CH06273A	Active	BPS-H80-003048	MAINLINE HEALTH SYSTEMS INC	WILMOT CLINIC	203 Mccombs St	Wilmot	AR
CH06273AA	Active	BPS-H80-035244	Mainline Health Systems Inc	Brunson Elementary School Behavioral Health Clinic	212 Scoby Dr	Warren	AR
CH06273AB	Active	BPS-H80-039929	Mainline Health Systems Inc	Warren High School Health Clinic	931 N Myrtle St, Building D	Warren	AR
CH06273AC	Terminated	BPS-H80-035245	Mainline Health Systems Inc	Warren Eastside School	408 N Bradley St	Warren	AR
CH06273AD	Active	BPS-H80-035243	Mainline Health Systems Inc	Warren Middle School Behavioral Health Center	210 Scoby Dr	Warren	AR
CH06273AE	Active	BPS-H80-035539	Mainline Health Systems Inc	East End Intermediate School Health Center	5205 West Sawmill Road	Little Rock	AR
CH06273AF	Terminated	BPS-H80-036689	MAINLINE HEALTH SYSTEMS INC	Mainline Health Women's Clinic McGehee	206 S 1st St	Mc Gehee	AR
CH06273AG	Active	BPS-H80-036832	MAINLINE HEALTH SYSTEMS INC	Warren Elementary School Clinic	2018 Lady Jack Drive	Warren	AR
CH06273AH	Active	BPS-H80-036864	MAINLINE HEALTH SYSTEMS INC	Mainline Health Women's Clinic Lake Village	2729 US-65	Lake Village	AR
CH06273AJ	Active	BPS-H80-037642	MAINLINE HEALTH SYSTEMS INC	Warren High School Behavioral Health Clinic	803 N Walnut St RM 214	Warren	AR
CH06273AK	Active	BPS-H80-033908	MAINLINE HEALTH SYSTEMS INC	Mainline Health Systems, Inc. Specialty Services	342 Highway 425 S	Monticello	AR
CH06273AL	Active	BPS-H80-038705	MAINLINE HEALTH SYSTEMS INC	PCSSD SBHC-Mills	1205 E Dixon Rd	Little Rock	AR
CH06273AM	Approved	BPS-H80-040001	MAINLINE HEALTH SYSTEMS INC	Dermott School Clinic	525 E Speedway St	Dermott	AR
CH06273AN	Approved	BPS-H80-039415	MAINLINE HEALTH SYSTEMS INC	Cleveland County School District Health Center	700 Main St	Rison	AR
CH06273B	Active	BPS-H80-004300	MAINLINE HEALTH SYSTEMS INC	EUDORA CLINIC	579 E Beouff St	Eudora	AR
CH06273C	Active	BPS-H80-009294	MAINLINE HEALTH SYSTEMS INC	Dermott Medical Clinic	300 S School St	Dermott	AR
CH06273D	Active	BPS-H80-017920	MAINLINE HEALTH SYSTEMS INC	Monticello Community Health Center	535 Jordan Dr.	Monticello	AR
CH06273F	Active	BPS-H80-018047	MAINLINE HEALTH SYSTEMS INC	Star City Community Health Center	110 N Drew St	Star City	AR
CH06273G	Terminated	BPS-H80-017473	MAINLINE HEALTH SYSTEMS INC	Portland Elementary School Based Clinic	314 Hwy 160 E	Portland	AR
CH06273H	Active	BPS-H80-017472	MAINLINE HEALTH SYSTEMS INC	Hamburg High School School Based Clinic	1119 S Main St	Hamburg	AR
CH06273J	Active	BPS-H80-017475	MAINLINE HEALTH SYSTEMS INC	Noble/Allbritton Elementary School Based Clinic	206 N Barlett St	Hamburg	AR
CH06273K	Terminated	BPS-H80-018879	MAINLINE HEALTH SYSTEMS INC	Dermott School Clinic	525 E Speedway St	Dermott	AR
CH06273L	Active	BPS-H80-019697	MAINLINE HEALTH SYSTEMS INC	Jimmy Brown Elementary - SCSD	310 Ashley Avenue	Star City	AR
CH06273M	Active	BPS-H80-019766	MAINLINE HEALTH SYSTEMS INC	Lakeside School	360 A Highway 82	Lake Village	AR
CH06273N	Active	BPS-H80-037716	MAINLINE HEALTH SYSTEMS INC	Star City High School Clinic	400 E Arkansas St RM E3	Star City	AR
CH06273P	Active	BPS-H80-021275	MAINLINE HEALTH SYSTEMS INC	Drew Central School District	250 University Drive	Monticello	AR
CH06273Q	Active	BPS-H80-024733	MAINLINE HEALTH SYSTEMS INC	Hamburg Middle School-SBHC	1109 Cub Drive	Hamburg	AR
CH06273R	Terminated	BPS-H80-021274	MAINLINE HEALTH SYSTEMS INC	Eudora Elementary Clinic	566 S Mabry St	Eudora	AR
CH06273S	Active	BPS-H80-027076	MAINLINE HEALTH SYSTEMS INC	Mainline Rison	505 Sycamore St.	Rison	AR
CH06273T	Active	BPS-H80-030144	MAINLINE HEALTH SYSTEMS INC	Mainline Health Systems, Inc.-Warren 2	1012 E Church St Ste B	Warren	AR
CH06273U	Active	BPS-H80-032904	Mainline Health Systems Inc	Mainline UAM Behavioral Health	517 University Dr	Monticello	AR
CH06273V	Active	BPS-H80-037806	Mainline Health Systems Inc	Warren Dental Clinic	800 N Walnut St	Warren	AR
CH06273W	Active	BPS-H80-038864	Mainline Health Systems Inc	Mainline UAM	136 University Ct	Monticello	AR
CH06273X	Active	BPS-H80-030513	Mainline Health Systems Inc	Star City Dental	557 Kirkwood Rd	Star City	AR
CH06273Y	Active	BPS-H80-034091	Mainline Health Systems Inc	Sheridan Clinic	506 Little Creek Cut Off Rd	Sheridan	AR
CH06273Z	Active	BPS-H80-034345	Mainline Health Systems Inc	Sheridan High School Clinic	512 W Church St STE A	Sheridan	AR

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH062730	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	07/01/2024
CH062730	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	07/01/2024
CH062730	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	07/01/2024
CH062730	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	07/01/2024
CH062730	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	07/01/2024
CH062730	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	07/01/2024
CH062730	ALLCARE SPECIALTY PHARMACY, LLC	10620 COLONEL GLENN RD STE 300		LITTLE ROCK	AR	72204-8048	10/01/2018
CH06273AE	ALLCARE SPECIALTY PHARMACY, LLC	10620 COLONEL GLENN RD STE 300		LITTLE ROCK	AR	72204-8048	01/01/2024
CH062730	BEARD DRUG INC	614 S LINCOLN AVE		STAR CITY	AR	71667-5802	04/01/2015
CH06273F	BEARD DRUG INC	614 S LINCOLN AVE		STAR CITY	AR	71667-5802	01/01/2024
CH062730	CAREFIRST PHARMACY AND WELLNESS CENTER	113 EAST ADAMS		HAMBURG	AR	71646	07/01/2024
CH062730	CITY DRUG OF MONTICELLO	201 E GAINES ST		MONTICELLO	AR	71655-4903	04/01/2018
CH06273P	CITY DRUG OF MONTICELLO	201 E GAINES ST		MONTICELLO	AR	71655-4903	01/01/2024
CH062730	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	07/01/2024
CH062730	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	07/01/2024
CH06273C	DELTA DRUG OF DERMOTT INC	111 E PEDDICORD ST		DERMOTT	AR	71638	01/28/2010	07/26/2019
CH06273D	DELTA DRUG OF DERMOTT INC	111 E PEDDICORD ST		DERMOTT	AR	71638	04/01/2018	07/26/2019
CH06273A	DELTA DRUG OF DERMOTT INC	111 E PEDDICORD ST		DERMOTT	AR	71638	04/01/2018	07/26/2019
CH062730	DELTA DRUG OF DERMOTT INC	111 E PEDDICORD ST		DERMOTT	AR	71638	04/01/2018
CH06273F	DELTA DRUG OF DERMOTT INC	111 E PEDDICORD ST		DERMOTT	AR	71638	04/01/2018	07/26/2019
CH06273H	DELTA DRUG OF DERMOTT INC	111 E PEDDICORD ST		DERMOTT	AR	71638	04/01/2018	07/26/2019
CH06273G	DELTA DRUG OF DERMOTT INC	111 E PEDDICORD ST		DERMOTT	AR	71638	04/01/2018	07/26/2019
CH06273B	DELTA DRUG OF DERMOTT INC	111 E PEDDICORD ST		DERMOTT	AR	71638	04/01/2018	07/26/2019
CH06273C	DELTA DRUG OF DERMOTT INC	111 E PEDDICORD ST		DERMOTT	AR	71638	01/01/2024
CH062730	DOCTOR'S ORDERS PHARMACY #2	DOCTOR'S ORDERS PHARMACY #2	2302 W 28TH AVE STE B	PINE BLUFF	AR	71603	01/01/2020
CH06273X	DOCTOR'S ORDERS PHARMACY #2	DOCTOR'S ORDERS PHARMACY #2	2302 W 28TH AVE STE B	PINE BLUFF	AR	71603	01/01/2024
CH062730	DOCTOR'S ORDERS PHARMACY #3	WHITEHALL PHARMACY LLC	500 S LINCOLN AVE	STAR CITY	AR	71667-5208	01/01/2020
CH06273V	DOCTOR'S ORDERS PHARMACY #3	WHITEHALL PHARMACY LLC	500 S LINCOLN AVE	STAR CITY	AR	71667-5208	01/01/2024
CH062730	DUMAS FAMILY PHARMACY LLC	301 HIGHWAY 65 S		DUMAS	AR	71639	08/31/2021
CH06273AF	DUMAS FAMILY PHARMACY LLC	301 HIGHWAY 65 S		DUMAS	AR	71639	01/01/2024	10/01/2024
CH062730	EAST END PHARMACY	20381 ARCH ST		LITTLE ROCK	AR	72206-9218	07/01/2022
CH06273AC	EAST END PHARMACY	20381 ARCH ST		LITTLE ROCK	AR	72206-9218	01/01/2024	01/01/2024
CH06273AG	EAST END PHARMACY	20381 ARCH ST		LITTLE ROCK	AR	72206-9218	04/01/2024
CH062730	EUDORA DRUG STORE	200 S. MAIN ST		EUDORA	AR	71640	10/01/2015	10/02/2015
CH062730	EUDORA DRUG STORE	200 S. MAIN ST		EUDORA	AR	71640	04/01/2018
CH06273R	EUDORA DRUG STORE	200 S. MAIN ST		EUDORA	AR	71640	01/01/2024	04/01/2025
CH06273A	FOOTE'S SUPER DRUG NO 4, INC		109 EAST ADAMS STREET PO BOX 8	HAMBURG	AR	71646	11/21/2009	01/14/2018
CH062730	FRED'S PHARMACY #1908	700 N MAIN ST		HAMBURG	AR	71646-2718	07/01/2015	10/11/2019
CH06273J	FRED'S PHARMACY #2371	406 HIGHWAY 425 SOUTH		MONTICELLO	AR	71655	04/01/2018	11/27/2018
CH06273H	FRED'S PHARMACY #2371	406 HIGHWAY 425 SOUTH		MONTICELLO	AR	71655	04/01/2018	11/27/2018
CH06273C	FRED'S PHARMACY #2371	406 HIGHWAY 425 SOUTH		MONTICELLO	AR	71655	04/01/2018	11/27/2018
CH06273N	FRED'S PHARMACY #2371	406 HIGHWAY 425 SOUTH		MONTICELLO	AR	71655	04/01/2018	11/27/2018
CH06273D	FRED'S PHARMACY #2371	406 HIGHWAY 425 SOUTH		MONTICELLO	AR	71655	04/01/2018	11/27/2018
CH06273L	FRED'S PHARMACY #2371	406 HIGHWAY 425 SOUTH		MONTICELLO	AR	71655	04/01/2018	11/27/2018
CH06273G	FRED'S PHARMACY #2371	406 HIGHWAY 425 SOUTH		MONTICELLO	AR	71655	04/01/2018	11/27/2018
CH06273F	FRED'S PHARMACY #2371	406 HIGHWAY 425 SOUTH		MONTICELLO	AR	71655	04/01/2018	11/27/2018
CH06273B	FRED'S PHARMACY #2371	406 HIGHWAY 425 SOUTH		MONTICELLO	AR	71655	04/01/2018	11/27/2018
CH06273A	FRED'S PHARMACY #2371	406 HIGHWAY 425 SOUTH		MONTICELLO	AR	71655	04/01/2018	11/27/2018
CH06273K	FRED'S PHARMACY #2371	406 HIGHWAY 425 SOUTH		MONTICELLO	AR	71655	04/01/2018	11/27/2018
CH06273K	FRED'S PHARMACY #2371	406 HIGHWAY 425 SOUTH		MONTICELLO	AR	71655	04/01/2018	11/27/2018
CH06273B	FRED'S PHARMACY #2371	406 HIGHWAY 425 SOUTH		MONTICELLO	AR	71655	04/01/2018	11/27/2018
CH062730	FRED'S PHARMACY #2371	406 HIGHWAY 425 SOUTH		MONTICELLO	AR	71655	04/01/2018	12/17/2018
CH06273M	FRED'S PHARMACY #2371	406 HIGHWAY 425 SOUTH		MONTICELLO	AR	71655	04/01/2018	11/27/2018
CH06273H	FRED'S PHARMACY #2371	406 HIGHWAY 425 SOUTH		MONTICELLO	AR	71655	04/01/2018	11/27/2018
CH062730	FRED'S PHARMACY #2981	1309 N LINCOLN AVE	HWY 425 NORTH	STAR CITY	AR	71667-4211	07/01/2015	10/09/2019
CH062730	GENOA HEALTHCARE LLC	8791 NORTHWEST DR		SOUTHAVEN	MS	38671	07/01/2024
CH06273H	HAMBURG PHARMACY	302 S MAIN ST		HAMBURG	AR	71646-3230	10/01/2019	07/23/2019
CH062730	HAMBURG PHARMACY	302 S MAIN ST		HAMBURG	AR	71646-3230	10/01/2019
CH06273J	HAMBURG PHARMACY	302 S MAIN ST		HAMBURG	AR	71646-3230	01/01/2024
CH062730	HUNTERS PHARMACY INC	401 MAIN ST		LAKE VILLAGE	AR	71653-1731	04/01/2018
CH06273M	HUNTERS PHARMACY INC	401 MAIN ST		LAKE VILLAGE	AR	71653-1731	01/01/2024
CH062730	INFINITY COMPOUNDING SOLUTIONS, LLC	DBA INFINITY CARE SOLUTIONS	1204 SE 28TH ST STE 2	BENTONVILLE	AR	72712-3887	07/01/2024
CH062730	KELLEY DRUG AND SELECTIONS	104 HOLLY STREET	P O BOX 21	MCGEHEE	AR	71654	01/01/2014	05/31/2019
CH062730	MAINLINE PHARMACY SERVICES, INC.	DBA: CLINIC PHARMACY OF MONTICELLO	535 JORDAN DR SUITE B	MONTICELLO	AR	71655-5714	08/31/2021
CH06273D	MAINLINE PHARMACY SERVICES, INC.	DBA: CLINIC PHARMACY OF MONTICELLO	535 JORDAN DR SUITE B	MONTICELLO	AR	71655-5714	01/01/2024
CH062730	MCCOY & TYGART DRUG STORE INC	821 N ROCK ST	P.O. BOX 217	SHERIDAN	AR	72150-7623	04/01/2022
CH06273Y	MCCOY & TYGART DRUG STORE INC	821 N ROCK ST	P.O. BOX 217	SHERIDAN	AR	72150-7623	01/01/2024
CH062730	MCGEHEE DRUG COMPANY	1007 HIGHWAY 65 S		MC GEHEE	AR	71654-9417	07/01/2022
CH06273G	MCGEHEE DRUG COMPANY	1007 HIGHWAY 65 S		MC GEHEE	AR	71654-9417	01/01/2024	04/01/2025
CH062730	MVP WARREN LLC	101 N MAIN ST		WARREN	AR	71671	01/01/2020
CH06273T	MVP WARREN LLC	101 N MAIN ST		WARREN	AR	71671	01/01/2024
CH062730	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	01/01/2025
CH062730	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	07/01/2024
CH062730	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	07/01/2024
CH062730	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	07/01/2024
CH062730	PHARM-MART PHARMACY OF WARREN INC.	DBA: WALGREENS #15817	310 SOUTH MARTIN	WARREN	AR	71671	10/01/2014
CH06273AB	PHARM-MART PHARMACY OF WARREN INC.	DBA: WALGREENS #15817	310 SOUTH MARTIN	WARREN	AR	71671	01/01/2024
CH062730	PORTLAND DRUG STORE	105 HIGHWAY 165 S		PORTLAND	AR	71663	10/01/2015	10/02/2015
CH062730	PORTLAND DRUG STORE	105 HIGHWAY 165 S		PORTLAND	AR	71663	04/01/2018
CH062730	REDFIELD PHARMACY MANAGEMENT	DBA REDFIELD PHARMACY	1017 SHERIDAN RD	REDFIELD	AR	72132-9356	07/01/2024
CH062730	SHERIDAN FAMILY PHARMACY LLC	677 HERITAGE DRIVE		SHERIDAN	AR	72150	04/01/2022
CH06273Z	SHERIDAN FAMILY PHARMACY LLC	677 HERITAGE DRIVE		SHERIDAN	AR	72150	01/01/2024
CH062730	SOUTHEAST ARKANSAS PHARMACIES LLC	DBA THE PRESCRIPTION PAD PHARMACY	539 HIGHWAY 425 S	MONTICELLO	AR	71655-4674	04/01/2016	01/03/2017
CH062730	SOUTHEAST ARKANSAS PHARMACIES LLC	DBA THE PRESCRIPTION PAD PHARMACY	539 HIGHWAY 425 S	MONTICELLO	AR	71655-4674	04/01/2018	03/01/2021
CH062730	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/01/2017
CH062730	WAL-MART PHARMACY 10-0167	910 UNITY RD		CROSSETT	AR	71635	04/01/2015
CH06273H	WAL-MART PHARMACY 10-0167	910 UNITY RD		CROSSETT	AR	71635	01/01/2024
CH062730	WAL-MART PHARMACY 10-0289	1001 HIGHWAY 65 S		MC GEHEE	AR	71654	07/01/2014
CH06273K	WAL-MART PHARMACY 10-0289	1001 HIGHWAY 65 S		MC GEHEE	AR	71654	01/01/2024	04/01/2025
CH062730	WAL-MART PHARMACY 10-0336	1308 SOUTH ROCK STREET		SHERIDAN	AR	72150	04/01/2022
CH06273L	WAL-MART PHARMACY 10-0336	1308 SOUTH ROCK STREET		SHERIDAN	AR	72150	01/01/2024
CH062730	WAL-MART PHARMACY 10-0339	1123 HIGHWAY 79/167 BYPASS	PO BOX 705	FORDYCE	AR	71742	04/01/2022
CH06273AA	WAL-MART PHARMACY 10-0339	1123 HIGHWAY 79/167 BYPASS	PO BOX 705	FORDYCE	AR	71742	01/01/2024
CH062730	WAL-MART PHARMACY 10-0348	427 HWY 425 NORTH		MONTICELLO	AR	71655	07/01/2014
CH06273W	WAL-MART PHARMACY 10-0348	427 HWY 425 NORTH		MONTICELLO	AR	71655	01/01/2024
CH062730	WAL-MART PHARMACY 10-1108	705 SO CONSTITUTION AVENUE		OAK GROVE	LA	71263	07/01/2024
CH062730	WAL-MART PHARMACY 10-3331	5501 SOUTH OLIVE ST		PINE BLUFF	AR	71603	07/01/2024
CH062730	WAL-MART PHARMACY 10-5315	2354 COMMERCE PARK DR.		ORLANDO	FL	32819	07/01/2024
CH062730	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/01/2017
CH062730	WALGREEN CO	DBA: WALGREENS #10666	640 W GAINES STREET	MONTICELLO	AR	71655-4675	05/10/2012
CH06273U	WALGREEN CO	DBA: WALGREENS #10666	640 W GAINES STREET	MONTICELLO	AR	71655-4675	01/01/2024
CH062730	WALGREEN CO.	DBA: WALGREENS # 09144	747 HIGHWAY 1 SOUTH	GREENVILLE	MS	38701-5958	05/10/2012	12/22/2020
CH062730	WALGREEN CO.	WALGREENS #21379	5905 DOLLARWAY RD	PINE BLUFF	AR	71602	04/01/2022
CH062730	WALGREEN CO.	WALGREENS #15361	2503 W 28TH AVE	PINE BLUFF	AR	71603	04/01/2022
CH06273AD	WALGREEN CO.	WALGREENS #15361	2503 W 28TH AVE	PINE BLUFF	AR	71603	01/01/2024
CH06273N	WALGREEN CO.	WALGREENS #21379	5905 DOLLARWAY RD	PINE BLUFF	AR	71602	01/01/2024
CH062730	WALGREEN CO.	WALGREENS #15714	500 S UNIVERSITY AVE GRND FL	LITTLE ROCK	AR	72205	07/01/2024
CH062730	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 10536	1930 E MADISON AVE	BASTROP	LA	71220-4034	05/10/2012	12/11/2015
CH062730	Walgreens #21389	Walgreens Central Fill #21389	3299 Tchulatech Dr Suite 101	Memphis	TN	38118	07/01/2022
CH062730	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/01/2025
CH062730	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/01/2025
CH062730	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/01/2025
CH062730	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	10/01/2023
CH062730	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024
CH062730	WARMACK PHARMACIES INC	D/B/A RISON PHARMACY	301 MAIN ST	RISON	AR	71665	04/01/2019
CH06273S	WARMACK PHARMACIES INC	D/B/A RISON PHARMACY	301 MAIN ST	RISON	AR	71665	01/01/2024
CH062730	WARMACK PHARMACIES INC	WATSON PHARMACY	802 W 4TH ST	FORDYCE	AR	71742-7174	07/01/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		NICHOLS, GARY ALLAN Executive Director Mainline Health Systems 8705385414	4/4/2025 2:41 PM
Details	340B ID	Update	New Registration		CH06273AM	4/4/2025 2:41 PM
Dates	Participating Approval Date	Update	New Registration		4/4/2025 2:41:48 PM	4/4/2025 2:41 PM
Details	State	Update	New Registration	Pending	Approved	4/4/2025 2:41 PM
Dates	Signed By Date	Update	New Registration		4/4/2025 11:13:34 AM	4/4/2025 2:41 PM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/4/2025 2:41 PM
Addresses	Main Address	Insert	New Registration		525 E Speedway St Dermott, AR 71638-2322	4/1/2025 4:12 PM
Addresses	Billing Address	Insert	New Registration		Mainline Health Systems, Inc. 342 Hwy 425 S Monticello, AR 71655	4/1/2025 4:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/1/2025 4:12 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		217430749	4/1/2025 4:12 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AR	4/1/2025 4:12 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1477004471	4/1/2025 4:12 PM
Medicaid Billing	NPI: State	Insert	New Registration		AR	4/1/2025 4:12 PM
Contacts	Authorizing Official	Insert	New Registration		NICHOLS, GARY ALLAN Executive Director Mainline Health Systems 8705385414	4/1/2025 4:12 PM
Contacts	Primary Contact	Insert	New Registration		Keller, Courtney PharmD Mainline Health Systems 8705385414	4/1/2025 4:12 PM
Details	Assistance Received From Date	Insert	New Registration			4/1/2025 4:12 PM
Details	Assistance Received To Date	Insert	New Registration			4/1/2025 4:12 PM
Details	Last Recertification Date	Insert	New Registration			4/1/2025 4:12 PM
Details	Grant Number	Insert	New Registration		H80CS00638	4/1/2025 4:12 PM
Details	340B ID	Insert	New Registration			4/1/2025 4:12 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/1/2025 4:12 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/1/2025 4:12 PM
Details	Medicare Provider Number	Insert	New Registration			4/1/2025 4:12 PM
Details	Entity Name	Insert	New Registration		MAINLINE HEALTH SYSTEMS INC	4/1/2025 4:12 PM
Details	NOFO Number	Insert	New Registration			4/1/2025 4:12 PM
Details	Program Code	Insert	New Registration		CH	4/1/2025 4:12 PM
Details	Entity Subname	Insert	New Registration		Dermott School Clinic	4/1/2025 4:12 PM
Dates	Participating Approval Date	Insert	New Registration			4/1/2025 4:12 PM
Details	State	Insert	New Registration		Pending	4/1/2025 4:12 PM
Dates	Registration Date	Insert	New Registration		4/1/2025 4:12:18 PM	4/1/2025 4:12 PM
Dates	Signed By Date	Insert	New Registration			4/1/2025 4:12 PM
Dates	Start Date	Insert	New Registration			4/1/2025 4:12 PM
Terminations	Termination Comments	Insert	New Registration			4/1/2025 4:12 PM
Terminations	Termination Date	Insert	New Registration			4/1/2025 4:12 PM
Terminations	Termination Effective Date	Insert	New Registration			4/1/2025 4:12 PM
Terminations	Termination Reason	Insert	New Registration			4/1/2025 4:12 PM

340B Drug Pricing Program Database