Covered Entity Details

CH01006Z FAIR HAVEN COMMUNITY HEALTH CLINIC, INC. (Approved) - information as of 5/3/2025 11:27:47 PM

Main Details

Name

FAIR HAVEN COMMUNITY HEALTH CLINIC, INC.

Subdivision Name

Fair Haven Community Health Care at 465 Grand Avenue

Type

HRSA-Funded Health Center

Site ID

BPS-H80-039694

340B ID

CH01006Z

Grant Number

H80CS00741

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

Fair Haven Community Health Clinic, Inc.
SUZANNE LAGARDE, CEO
(203) 752-5129

Primary Contact

Fair Haven Community Health Clinic
Manan Dave, Compliance Officer
(203) 777-7411 Ext: 5198

Addresses

Street Address

645 Grand Ave
New Haven, CT 06511-5011

Billing Address

Fair Haven Community Health Clinic
374 Grand Avenue
New Haven, CT 06513

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?
No

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
CH010060	Active	BPS-H80-001277	FAIR HAVEN COMMUNITY HEALTH CLINIC INC	FAIR HAVEN COMMUNITY HEALTH CENTER	374 Grand Ave	New Haven	CT
CH01006A	Active	BPS-H80-000716	FAIR HAVEN COMMUNITY HEALTH CLINIC INC	WILBUR CROSS HIGH SCHOOL BODYSHP	181 MITCHELL DR	NEW HAVEN	CT
CH01006B	Active	BPS-H80-006676	FAIR HAVEN COMMUNITY HEALTH CLINIC INC	MARTINEZ K-8 SCHOOL BASED HC	100 JAMES ST	NEW HAVEN	CT
CH01006C	Active	BPS-H80-003567	FAIR HAVEN COMMUNITY HEALTH CLINIC INC	FAIR HAVEN MEDICAL GROUP - BELLA VISTA	339 Eastern St	New Haven	CT
CH01006D	Terminated	BPS-H80-006050	FAIR HAVEN COMMUNITY HEALTH CLINIC INC	RIVERSIDE ACADEMY	560 ELLA T. GRASSO BLVD	NEW HAVEN	CT
CH01006E	Active	BPS-H80-004077	FAIR HAVEN COMMUNITY HEALTH CLINIC INC	FAIR HAVEN K-8 SCHOOL HLTH	164 Grand Ave	New Haven	CT
CH01006F	Active	BPS-H80-010636	FAIR HAVEN COMMUNITY HEALTH CLINIC INC	Clinton Avenue School Based Health Center	293 Clinton Ave	NEW HAVEN	CT
CH01006H	Terminated	BPS-H80-013687	FAIR HAVEN COMMUNITY HEALTH CLINIC INC	"Smiles 2 Go" Dental Van	374 GRAND AVE	NEW HAVEN	CT
CH01006J	Active	BPS-H80-014260	FAIR HAVEN COMMUNITY HEALTH CLINIC INC	Fair Haven Community Health Center @ 50 Grand	50 GRAND AVE	NEW HAVEN	CT
CH01006K	Active	BPS-H80-017515	FAIR HAVEN COMMUNITY HEALTH CLINIC INC	Multicultural Ambulatory Addictions Services	426 East Street	New Haven	CT
CH01006L	Terminated	BPS-H80-017536	FAIR HAVEN COMMUNITY HEALTH CLINIC INC	Fair Haven Community Health Center @ East Haven	370 Hemingway Avenue	East Haven	CT
CH01006M	Active	BPS-H80-039451	Fair Haven Community Health Clinic Inc	BHcare	28 Branford road	North Branford	CT
CH01006N	Active	BPS-H80-019576	Fair Haven Community Health Clinic Inc	Joseph Melillo Middle School	67 Hudson St	East Haven	CT
CH01006P	Active	BPS-H80-019577	Fair Haven Community Health Clinic Inc	East Haven High School	35 Wheelbarrow Ln	East Haven	CT
CH01006Q	Active	BPS-H80-024620	Fair Haven Community Health Clinic Inc	Shoreline Family Health Care	221 W Main St	Branford	CT
CH01006R	Active	BPS-H80-030929	Fair Haven Community Health Clinic Inc	Fair Haven Community Health Care at 150 Sargent Drive	150 Sargent Dr Ste 1-300	New Haven	CT
CH01006S	Active	BPS-H80-033997	FAIR HAVEN COMMUNITY HEALTH CLINIC INC	Bishop Woods Architecture and Design Magnet School Based Health Center	1481 Quinnipiac Ave	New Haven	CT
CH01006T	Active	BPS-H80-036650	FAIR HAVEN COMMUNITY HEALTH CLINIC, INC.	Leeway House	40 Albert Street RM MC 1	New Haven	CT
CH01006U	Active	BPS-H80-036947	FAIR HAVEN COMMUNITY HEALTH CLINIC, INC.	Ross Woodward School Based Health Center	185 Barnes Ave	New Haven	CT
CH01006V	Active	BPS-H80-037369	FAIR HAVEN COMMUNITY HEALTH CLINIC, INC.	Metropolitan Business Academy	115 Water St	New Haven	CT
CH01006W	Active	BPS-H80-034415	FAIR HAVEN COMMUNITY HEALTH CLINIC, INC.	John B. Sliney Elementary School	23 Eades St	Branford	CT
CH01006X	Active	BPS-H80-028284	FAIR HAVEN COMMUNITY HEALTH CLINIC, INC.	Family Academy of Multi-Lingual Exploration (FAME)	255 Blatchley Ave	New Haven	CT
CH01006Y	Active	BPS-H80-034414	FAIR HAVEN COMMUNITY HEALTH CLINIC, INC.	Mary R. Tisko Elementary School	118 Damascus Rd	Branford	CT
CH01006Z	Approved	BPS-H80-039694	FAIR HAVEN COMMUNITY HEALTH CLINIC, INC.	Fair Haven Community Health Care at 465 Grand Avenue	645 Grand Ave	New Haven	CT

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH01006C	BELLA VISTA PHARMACY	321 EASTERN ST BLDG A		NEW HAVEN	CT	06513	10/25/2010
CH010060	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/01/2023
CH010060	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/01/2023
CH010060	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/01/2023
CH010060	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/01/2023
CH010060	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/01/2022
CH010060	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/01/2022
CH010060	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/01/2023
CH010060	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/01/2022
CH010060	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/01/2022
CH010060	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/01/2023
CH010060	COLUMBUS CHEMISTS LLC	BERNEYS PHARMACY	615 HOWARD AVE	NEW HAVEN	CT	06519-2112	01/01/2016	09/19/2016
CH010060	COMMUNITY HEALTH RX #2, INC.	221 W MAIN ST		BRANFORD	CT	06405-4022	07/01/2020	12/31/2020
CH010060	CONNECTICUT CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00857	660 FOXON RD.	EAST HAVEN	CT	06513	01/01/2020
CH010060	CONNECTICUT CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 01968	369 MAIN STREET	EAST HAVEN	CT	06512	01/01/2020
CH010060	CONNECTICUT CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02259	215 WHALLEY AVENUE	NEW HAVEN	CT	06511	01/01/2020	02/01/2022
CH010060	CONNECTICUT CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00172	2-6 SHORT BEACH RD,	BRANFORD	CT	06405	07/01/2020
CH010060	CONNECTICUT CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00692	162 WASHINGTON AVENUE	NORTH HAVEN	CT	06473	07/01/2020
CH010060	CONNECTICUT CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00775	2045 DIXWELL AVE.	HAMDEN	CT	06514	07/01/2020
CH010060	CONNECTICUT CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02584	252 ORANGE AVENUE	WEST HAVEN	CT	06516	07/01/2020	06/22/2022
CH010060	CONNECTICUT CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY #388	613 BOSTON POST RD	MADISON	CT	06443	07/01/2022
CH010060	CONNECTICUT CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00811	1150 WHALLEY AVENUE	NEW HAVEN	CT	06515	07/01/2022
CH010060	CONNECTICUT CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 935	891 NORTH COLONY RD.	WALLINGFORD	CT	06492	07/01/2022
CH010060	CONNECTICUT CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00941	844 JONES HILL ROAD	WEST HAVEN	CT	06516-5643	07/01/2022
CH010060	CONNECTICUT CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 01148	905 SOUTH MAIN ST.	CHESHIRE	CT	06410	07/01/2022
CH010060	CONNECTICUT CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 01284	17 WEST MAIN STREET	CLINTON	CT	06413	07/01/2022
CH010060	CONNECTICUT CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02097	279 BOSTON POST RD.	ORANGE	CT	06477	07/01/2022
CH010060	CONNECTICUT CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY #3549	355 CAMPBELL AVE.	WEST HAVEN	CT	06516-5329	07/01/2022
CH010060	CONNECTICUT CVS PHARMACY, L.L.C.	CVS/PHARMACY # 11007	123 CHURCH ST.	NEW HAVEN	CT	06510	07/01/2022
CH010060	CONNECTICUT CVS PHARMACY, L.L.C.	CVS PHARMACY # 17034	200 UNIVERSAL DR N	NORTH HAVEN	CT	06473	07/01/2022
CH010060	CONNECTICUT CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00718	24 PERSHING DR # 36	ANSONIA	CT	06401-2214	07/01/2023
CH010060	CONNECTICUT CVS PHARMACY, L.L.C.	CVS/PHARMACY # 11081	1245 DIXWELL AVE	HAMDEN	CT	06514	07/01/2023
CH01006A	CONNECTICUT CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00857	660 FOXON RD.	EAST HAVEN	CT	06513	07/01/2024
CH01006P	CONNECTICUT CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00775	2045 DIXWELL AVE.	HAMDEN	CT	06514	07/01/2024
CH01006N	CONNECTICUT CVS PHARMACY, L.L.C.	CVS/PHARMACY # 11081	1245 DIXWELL AVE	HAMDEN	CT	06514	07/01/2024
CH01006S	CONNECTICUT CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 01968	369 MAIN STREET	EAST HAVEN	CT	06512	07/01/2024
CH010060	CONNECTICUT PHARMACY EAST ROCK LTC, LLC	EAST ROCK PHARMACY	10 FAIRFIELD BLVD UNIT C2	WALLINGFORD	CT	06492-5903	07/01/2015	02/22/2016
CH010060	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/01/2023
CH010060	HANCOCK PHARMACY VII	306 GRAND AVE		NEW HAVEN	CT	06513	08/11/2010
CH01006E	HANCOCK PHARMACY VII	306 GRAND AVE		NEW HAVEN	CT	06513	07/01/2024
CH010060	MY FAIR HAVEN PHARMACY LLC	D/B/A FAIR HAVEN PHARMACY	72 GRAND AVE	NEW HAVEN	CT	06513	01/01/2016	01/12/2021
CH010060	NEW HAVEN PHARMACY INC	374 GRAND AVE		NEW HAVEN	CT	06513	10/01/2015
CH01006Q	NEW HAVEN PHARMACY INC	374 GRAND AVE		NEW HAVEN	CT	06513	07/01/2024
CH010060	PHARMERICA	PHARMACY CORPORATION OF AMERICA	8 FAIRFIELD BLVD. STE 103	WALLINGFORD	CT	06492-1423	10/01/2023
CH01006T	PHARMERICA	PHARMACY CORPORATION OF AMERICA	8 FAIRFIELD BLVD. STE 103	WALLINGFORD	CT	06492-1423	07/01/2024
CH010060	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/01/2022
CH010060	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/01/2023
CH010060	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	07/01/2023
CH010060	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/01/2023
CH010060	RITE AID OF CONNECTICUT, INC.	RITE AID #1882	325 FERRY STREET	NEW HAVEN	CT	06513	04/01/2016	12/04/2023
CH010060	RITE AID OF CONNECTICUT, INC.	RITE AID #4778	588 MAIN STREET	EAST HAVEN	CT	06512	04/01/2017	09/19/2023
CH010060	RITE AID OF CONNECTICUT, INC.	RITE AID #1839	70 ELM STREET	WEST HAVEN	CT	06516	07/01/2018	11/29/2023
CH010060	RITE AID OF CONNECTICUT, INC.	RITE AID #4092	645 FOXON ROAD	EAST HAVEN	CT	06513	07/01/2018	09/07/2023
CH010060	RITE AID OF CONNECTICUT, INC.	RITE AID #1033	85 MIDDLETOWN AVENUE	NORTH HAVEN	CT	06473	07/01/2019	02/24/2022
CH010060	RITE AID OF CONNECTICUT, INC.	RITE AID #3264	10 HEMINGWAY AVENUE	EAST HAVEN	CT	06512	07/01/2019	07/15/2024
CH010060	RITE AID OF CONNECTICUT, INC.	RITE AID #441	66 CHURCH STREET	NEW HAVEN	CT	06510	07/01/2019	12/11/2023
CH010060	VALUE HEALTH CARE SERVICES, LLC	OMNICARE OF CONNECTICUT	525 KNOTTER DRIVE	CHESHIRE	CT	06410	01/01/2025
CH010060	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	10/01/2017
CH010060	WAL-MART PHARMACY 10-2232	120 COMMERCIAL PKWY		BRANFORD	CT	06405	04/01/2016	08/28/2016
CH010060	WAL-MART PHARMACY 10-3545	2300 DIXWELL AVENUE		HAMDEN	CT	06514	04/01/2016	08/28/2016
CH010060	WAL-MART PHARMACY 10-5315	2354 COMMERCE PARK DR.		ORLANDO	FL	32819	07/01/2018	04/08/2019
CH010060	WAL-MART PHARMACY 10-5439	315 FOXON BLVD		NEW HAVEN	CT	06513	04/01/2016
CH010060	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	10/01/2017
CH010060	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 03579	1471 WHALLEY AVENUE	NEW HAVEN	CT	06515	01/01/2013	11/13/2024
CH010060	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 05406	1191 DIXWELL AVE	HAMDEN	CT	06514	01/01/2013
CH010060	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #06474	88 YORK ST	NEW HAVEN	CT	06511-5619	01/01/2013
CH010060	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 06914	87 FOXON ST	NEW HAVEN	CT	06513-2365	01/01/2013
CH010060	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 07584	394 CAMPBELL AVE	WEST HAVEN	CT	06516-5012	01/01/2013
CH010060	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 07935	54 BOSTON POST RD	ORANGE	CT	06477-3201	01/01/2013	05/03/2023
CH010060	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 09071	49 WASHINGTON AVE	NORTH HAVEN	CT	06473-1704	01/01/2013
CH010060	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 09101	2505 WHITNEY AVENUE	HAMDEN	CT	06518-3019	01/01/2013
CH010060	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #9785	436 WHALLEY AVENUE	NEW HAVEN	CT	06511-3012	01/01/2013	03/20/2025
CH010060	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #12120	157 MAIN ST	EAST HAVEN	CT	06512	01/01/2013
CH010060	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #13944	60 TEMPLE ST	NEW HAVEN	CT	06510	01/01/2013	12/04/2017
CH010060	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #13947	1415 CHAPEL ST	NEW HAVEN	CT	06511	01/01/2013	02/17/2020
CH010060	WALGREEN EASTERN CO., INC.	DBA WALGREENS SPECIALTY PHARMACY #13969	55 PARK ST STE 1A	NEW HAVEN	CT	06511	10/01/2016
CH010060	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #13945	800 HOWARD AVE STE 197	NEW HAVEN	CT	06519-1369	01/01/2018	01/21/2021
CH010060	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 03944	329 E MAIN ST	BRANFORD	CT	06405	01/01/2022
CH010060	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #10309	1036 W MAIN ST	BRANFORD	CT	06405	01/01/2022
CH010060	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 02410	1697 WHITNEY AVE STE 3	HAMDEN	CT	06517	01/01/2022
CH010060	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 01451	1083 BOSTON POST RD	MILFORD	CT	06460-3550	07/01/2022	04/21/2025
CH010060	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 03359	1606 BARNUM AVE	STRATFORD	CT	06614-5301	07/01/2022
CH010060	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 05948	425 W MAIN ST	MERIDEN	CT	06451	07/01/2022
CH010060	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #10647	284 S COLONY RD	WALLINGFORD	CT	06492	07/01/2022
CH01006R	WALGREEN EASTERN CO., INC.	DBA WALGREENS SPECIALTY PHARMACY #13969	55 PARK ST STE 1A	NEW HAVEN	CT	06511	07/01/2024
CH01006K	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 05406	1191 DIXWELL AVE	HAMDEN	CT	06514	07/01/2024
CH01006B	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 06914	87 FOXON ST	NEW HAVEN	CT	06513-2365	07/01/2024
CH01006M	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #06474	88 YORK ST	NEW HAVEN	CT	06511-5619	07/01/2024
CH01006F	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #12120	157 MAIN ST	EAST HAVEN	CT	06512	07/01/2024
CH010060	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/01/2023
CH010060	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	07/01/2023
CH010060	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/01/2023	01/01/2024
CH010060	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		LAGARDE, SUZANNE CEO Fair Haven Community Health Clinic, Inc. 2037525129	4/4/2025 9:52 AM
Details	340B ID	Update	New Registration		CH01006Z	4/4/2025 9:52 AM
Dates	Participating Approval Date	Update	New Registration		4/4/2025 9:52:33 AM	4/4/2025 9:52 AM
Details	State	Update	New Registration	Pending	Approved	4/4/2025 9:52 AM
Dates	Signed By Date	Update	New Registration		4/4/2025 6:26:18 AM	4/4/2025 9:52 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/4/2025 9:52 AM
Addresses	Main Address	Insert	New Registration		645 Grand Ave New Haven, CT 06511-5011	4/1/2025 4:46 PM
Addresses	Billing Address	Insert	New Registration		Fair Haven Community Health Clinic 374 Grand Avenue New Haven, CT 06513	4/1/2025 4:46 PM
Contacts	Authorizing Official	Insert	New Registration		LAGARDE, SUZANNE CEO Fair Haven Community Health Clinic, Inc. 2037525129	4/1/2025 4:46 PM
Contacts	Primary Contact	Insert	New Registration		Dave, Manan Compliance Officer Fair Haven Community Health Clinic 2037777411-5198	4/1/2025 4:46 PM
Details	Assistance Received From Date	Insert	New Registration			4/1/2025 4:46 PM
Details	Assistance Received To Date	Insert	New Registration			4/1/2025 4:46 PM
Details	Last Recertification Date	Insert	New Registration			4/1/2025 4:46 PM
Details	Grant Number	Insert	New Registration		H80CS00741	4/1/2025 4:46 PM
Details	340B ID	Insert	New Registration			4/1/2025 4:46 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/1/2025 4:46 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/1/2025 4:46 PM
Details	Medicare Provider Number	Insert	New Registration			4/1/2025 4:46 PM
Details	Entity Name	Insert	New Registration		FAIR HAVEN COMMUNITY HEALTH CLINIC, INC.	4/1/2025 4:46 PM
Details	NOFO Number	Insert	New Registration			4/1/2025 4:46 PM
Details	Program Code	Insert	New Registration		CH	4/1/2025 4:46 PM
Details	Entity Subname	Insert	New Registration		Fair Haven Community Health Care at 465 Grand Avenue	4/1/2025 4:46 PM
Dates	Participating Approval Date	Insert	New Registration			4/1/2025 4:46 PM
Details	State	Insert	New Registration		Pending	4/1/2025 4:46 PM
Dates	Registration Date	Insert	New Registration		4/1/2025 4:46:06 PM	4/1/2025 4:46 PM
Dates	Signed By Date	Insert	New Registration			4/1/2025 4:46 PM
Dates	Start Date	Insert	New Registration			4/1/2025 4:46 PM
Terminations	Termination Comments	Insert	New Registration			4/1/2025 4:46 PM
Terminations	Termination Date	Insert	New Registration			4/1/2025 4:46 PM
Terminations	Termination Effective Date	Insert	New Registration			4/1/2025 4:46 PM
Terminations	Termination Reason	Insert	New Registration			4/1/2025 4:46 PM

340B Drug Pricing Program Database