Covered Entity Details

CH101188D Community Council of Idaho, Inc. (Active) - information as of 5/30/2025 6:54:29 PM

Main Details

Name

Community Council of Idaho, Inc.

Subdivision Name

Community Family Clinic Blackfoot

Type

HRSA-Funded Health Center

Site ID

BPS-H80-034851

340B ID

CH101188D

Grant Number

H80CS04201

Additional Details

Current Program Status

Active

Registration Date

12/5/2005

Participating Start Date

12/6/2005

Participating Approval Date

12/6/2005

Last Recertification Date

2/13/2025

Contacts

Authorizing Official

Community Council of Idaho
Arnold Cantu, ADMINISTRATOR
(208) 528-7655 Ext: 3519

Primary Contact

Community Council of Idaho
Troy Coulson, Pharmacy Operations Officer
(208) 470-7979

Addresses

Street Address

1491 Parkway Dr
BLACKFOOT, ID 83221

Billing Address

Community Council of Idaho DBA Community Family Clinic
2100 Alan Street
IDAHO FALLS, ID 83404

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
ID	1487302527,1710925250,1356416861	1487302527,1710925250,1356416861

Shipping Addresses

Shipping Address 1

Community Council of Idaho DBA Community Family Clinic Pharmacy
1491 Parkway Dr
Blackfoot, ID 83221

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
Contract Detail	PRESCRIPTION CENTER INC	2252 CORONADO ST		IDAHO FALLS	ID	83404	04/15/2022	07/01/2022		10/06/2023	10/06/2023

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH101188B	Active	BPS-H80-021817	Community Council of Idaho, Inc.	Community Family Clinic Idaho Falls	2100 Alan STREET	IDAHO FALLS	ID
CH101188C	Active	BPS-H80-033883	Community Council of Idaho, Inc.	Community Family Clinic Rigby	4002 E. 397 N. STE 3	Rigby	ID
CH101188D	Active	BPS-H80-034851	Community Council of Idaho, Inc.	Community Family Clinic Blackfoot	1491 Parkway Dr	BLACKFOOT	ID

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	City	State	Zip Code	Begin Date	Termination Date
CH101188B	PRESCRIPTION CENTER INC	2252 CORONADO ST	IDAHO FALLS	ID	83404	04/28/2006
CH101188C	PRESCRIPTION CENTER INC	2252 CORONADO ST	IDAHO FALLS	ID	83404	04/28/2006
CH101188D	PRESCRIPTION CENTER INC	2252 CORONADO ST	IDAHO FALLS	ID	83404	07/01/2022	10/06/2023
CH101188B	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300	SPRING	TX	77386	07/01/2022
CH101188B	WAL-MART PHARMACY 10-1902	1201 SOUTH 25TH EAST	AMMON	ID	83406	07/01/2022
CH101188B	WAL-MART PHARMACY 10-5494	500 SOUTH UTAH AVENUE	IDAHO FALLS	ID	83402	07/01/2022
CH101188B	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100	ORLANDO	FL	32837	07/01/2022

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Billing Address	Update	Recertification	Community Council of Idaho 2100 Alan Street IDAHO FALLS, ID 83404	Community Council of Idaho DBA Community Family Clinic 2100 Alan Street IDAHO FALLS, ID 83404	2/13/2025 12:32 PM
Details	Last Recertification Date	Update	Recertification	1/30/2024 4:44:27 PM	2/13/2025 12:32:00 PM	2/13/2025 12:32 PM
Contacts	Primary Contact	Update	Profile Change Request	Coulson, Troy Pharmacy Director Community Council of Idaho 2084707979	Coulson, Troy Pharmacy Operations Officer Community Council of Idaho 2084707979	2/13/2025 11:38 AM
Details	Last Recertification Date	Update	Recertification	1/30/2023 4:48:39 PM	1/30/2024 4:44:27 PM	1/30/2024 4:44 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/27/2023 12:42 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1356416861	7/27/2023 12:42 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	7/27/2023 12:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1356416861	7/27/2023 12:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	7/27/2023 12:42 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/10/2023 1:14 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1710925250	3/10/2023 1:14 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	3/10/2023 1:14 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1710925250	3/10/2023 1:14 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	3/10/2023 1:14 PM
Details	Last Recertification Date	Update	Recertification	2/9/2022 6:17:30 PM	1/30/2023 4:48:39 PM	1/30/2023 4:48 PM
Addresses	Shipping Address	Insert	Change Request		Community Council of Idaho DBA Community Family Clinic Pharmacy 1491 Parkway Dr Blackfoot, ID 83221	10/19/2022 1:15 PM
Addresses	Main Address	Update	Change Request	625 W. PACIFIC AVE Suite 3 BLACKFOOT, ID 83221	1491 Parkway Dr BLACKFOOT, ID 83221	10/18/2022 3:15 PM
Details	Entity Name	Update	Change Request	Community Council of Idaho Inc.	Community Council of Idaho, Inc.	10/18/2022 3:15 PM
Details	Entity Subname	Update	Change Request	COMMUNITY FAMILY CLINIC	Community Family Clinic Blackfoot	10/18/2022 3:15 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2022 1:29 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1487302527	6/15/2022 1:29 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	6/15/2022 1:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1487302527	6/15/2022 1:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	6/15/2022 1:29 PM
Contacts	Primary Contact	Update	Change Request	Alvarez, Daisy Office Manager Community Council of Idaho 2085287655-3510	Coulson, Troy Pharmacy Director Community Council of Idaho 2084707979	3/3/2022 12:12 PM
Details	Entity Name	Update	Change Request	IDAHO MIGRANT COUNCIL	Community Council of Idaho Inc.	3/3/2022 12:12 PM
Details	Last Recertification Date	Update	Recertification	2/1/2021 3:43:51 PM	2/9/2022 6:17:30 PM	2/9/2022 6:17 PM
Details	Last Recertification Date	Update	Recertification	1/27/2020 1:13:39 PM	2/1/2021 3:43:51 PM	2/1/2021 3:43 PM
Details	Last Recertification Date	Update	Recertification	1/30/2019 12:38:59 PM	1/27/2020 1:13:39 PM	1/27/2020 1:13 PM
Details	Last Recertification Date	Update	Recertification	2/27/2018 4:28:54 PM	1/30/2019 12:38:59 PM	1/30/2019 12:38 PM
Addresses	Billing Address	Update	Recertification	Community Council of Idaho 2088 E 25TH STREET IDAHO FALLS, ID 83404	Community Council of Idaho 2100 Alan Street IDAHO FALLS, ID 83404	2/27/2018 4:28 PM
Contacts	Primary Contact	Update	Recertification	Cantu, Arnold ADMINISTRATOR Community Council of Idaho 2085287655-3519	Alvarez, Daisy Office Manager Community Council of Idaho 2085287655-3510	2/27/2018 4:28 PM
Details	Last Recertification Date	Update	Recertification	1/25/2017 12:00:00 AM	2/27/2018 4:28:54 PM	2/27/2018 4:28 PM
Contacts	Authorizing Official	Update		Cantu, Arnold ADMINISTRATOR 2085287655-3519	Cantu, Arnold ADMINISTRATOR Community Council of Idaho 2085287655-3519	2/27/2018 4:09 PM
Contacts	Primary Contact	Update		Cantu, Arnold ADMINISTRATOR 2085287655-3519	Cantu, Arnold ADMINISTRATOR Community Council of Idaho 2085287655-3519	2/27/2018 4:09 PM
Addresses	Main Address	Insert			625 W. PACIFIC AVE Suite 3 BLACKFOOT, ID 83221	1/25/2017 1:02 PM
Contacts	Authorizing Official	Update		ANDREWS, GUY ADMINISTRATOR 2085287655-3507	Cantu, Arnold ADMINISTRATOR 2085287655-3519	1/25/2017 1:02 PM
Contacts	Primary Contact	Update		ANDREWS, GUY ADMINISTRATOR 2085287655-3507	Cantu, Arnold ADMINISTRATOR 2085287655-3519	1/25/2017 1:02 PM
Details	Last Recertification Date	Update		2/12/2016 12:00:00 AM	1/25/2017 12:00:00 AM	1/25/2017 1:02 PM
Details	Last Recertification Date	Update		3/2/2015 12:00:00 AM	2/12/2016 12:00:00 AM	2/12/2016 4:51 PM
Details	Last Recertification Date	Update		3/13/2014 12:00:00 AM	3/2/2015 12:00:00 AM	3/2/2015 1:04 PM
Details	Last Recertification Date	Update		4/1/2013 12:00:00 AM	3/13/2014 12:00:00 AM	3/13/2014 3:24 PM
Addresses	Billing Address	Insert			IDAHO MIGRANT COUNCIL 2088 E 25TH STREET IDAHO FALLS, ID 83404	3/14/2013 9:03 AM
Addresses	Billing Address	Update		IDAHO MIGRANT COUNCIL 2088 E 25TH STREET IDAHO FALLS, ID 83404	Community Council of Idaho 2088 E 25TH STREET IDAHO FALLS, ID 83404	3/14/2013 9:03 AM
Details	Last Recertification Date	Update			4/1/2013 12:00:00 AM	3/14/2013 9:03 AM
Contacts	Authorizing Official	Insert			ANDREWS, GUY ADMINISTRATOR 2085287655-3507	12/6/2005 9:52 AM
Contacts	Primary Contact	Insert			ANDREWS, GUY ADMINISTRATOR 2085287655-3507	12/6/2005 9:52 AM
Details	Last Recertification Date	Insert				12/6/2005 9:52 AM
Details	Grant Number	Insert			H80CS04201	12/6/2005 9:52 AM
Details	340B ID	Insert			CH101188D	12/6/2005 9:52 AM
Details	Is Authorizing Official EHB Data	Insert				12/6/2005 9:52 AM
Dates	Last Date That 340B Drugs Purchased	Insert				12/6/2005 9:52 AM
Details	Medicare Provider Number	Insert				12/6/2005 9:52 AM
Details	Entity Name	Insert			IDAHO MIGRANT COUNCIL	12/6/2005 9:52 AM
Details	Program Code	Insert			CH	12/6/2005 9:52 AM
Details	Entity Subname	Insert			COMMUNITY FAMILY CLINIC	12/6/2005 9:52 AM
Dates	Participating Approval Date	Insert			12/6/2005 12:00:00 AM	12/6/2005 9:52 AM
Details	State	Insert			Active	12/6/2005 9:52 AM
Dates	Registration Date	Insert			12/5/2005 12:00:00 AM	12/6/2005 9:52 AM
Dates	Signed By Date	Insert			8/31/2005 12:00:00 AM	12/6/2005 9:52 AM
Dates	Start Date	Insert			12/6/2005 12:00:00 AM	12/6/2005 9:52 AM
Terminations	Termination Comments	Insert				12/6/2005 9:52 AM
Terminations	Termination Date	Insert				12/6/2005 9:52 AM
Terminations	Termination Effective Date	Insert				12/6/2005 9:52 AM
Terminations	Termination Reason	Insert				12/6/2005 9:52 AM

340B Drug Pricing Program Database