Covered Entity Details

CH09078M Community Medical Centers, Inc. (Active) - information as of 5/16/2025 11:23:19 PM

Main Details

Name

Community Medical Centers, Inc.

Subdivision Name

Community Medical Centers, Lodi

Type

HRSA-Funded Health Center

Site ID

BPS-H80-000928

340B ID

CH09078M

Grant Number

H80CS00138

Additional Details

Current Program Status

Active

Registration Date

9/5/2006

Participating Start Date

10/1/2006

Participating Approval Date

9/5/2006

Last Recertification Date

2/21/2025

Contacts

Authorizing Official

Community Medical Centers, inc.
Greg Diederich, CEO
(209) 373-2826

Primary Contact

Community Medical Centers, Inc.
Pak Hui, Director of Pharmacy
(209) 940-4677

Addresses

Street Address

2401 W. Turner Rd
Suite 450
Lodi, CA 95242-2191

Billing Address

Community Medical Centers, Inc.
PO Box 779
Stockton, CA 95201-0779

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
CA	FHC70460F	1881685964,1710009659

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
Contract Detail	RALEY'S PHARMACY #445	311 SOUTH LOWER SACRAMENTO RD.		LODI	CA	95242	01/13/2011	01/13/2011			01/23/2015

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	Address Cont.	City	State
CH090780	Active	BPS-H80-002828	Community Medical Centers, Inc.	Community Medical Centers, Channel	701 E Channel St.		Stockton	CA
CH09078A	Terminated	BPS-H80-003590	Community Medical Centers, Inc.	Community Medical Centers, California Street	230 N California St		Stockton	CA
CH09078AA	Active	BPS-H80-021849	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, Tracy Grant Line Road	2151 W. Grant Line Rd		Tracy	CA
CH09078AB	Active	BPS-H80-019260	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, West Lane	7912 West Lane	Suite 221	Stockton	CA
CH09078AC	Active	BPS-H80-027181	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, California Street	2349 N California St		Stockton	CA
CH09078AD	Terminated	BPS-H80-027253	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, Edison High School	1425 S Center St		Stockton	CA
CH09078AE	Terminated	BPS-H80-027908	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, Vine Suite 100	2415 W Vine St	Suite 100	Lodi	CA
CH09078AF	Terminated	BPS-H80-027907	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, Vine Suite 105	2415 W Vine St.	Suite 105	Lodi	CA
CH09078AG	Active	BPS-H80-030442	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, Sutter Street	1800 S Sutter St	Ste 11B	Stockton	CA
CH09078AH	Active	BPS-H80-031502	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, Delta College Health Center	5151 Pacific Avenue, Locke Center, Room 126		Stockton	CA
CH09078AJ	Active	BPS-H80-031503	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, 747 Channel	747 E Channel St		Stockton	CA
CH09078AK	Active	BPS-H80-031884	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, St. Mary's Dining Room	545 W Sonora St Bldg 1		Stockton	CA
CH09078AL	Active	BPS-H80-031640	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, Mobile Unit 101	2650 Wigwam Drive, Unit 0		Stockton	CA
CH09078AM	Active	BPS-H80-031641	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, Mobile Unit 102	2650 Wigwam Drive, Unit 0		Stockton	CA
CH09078AN	Active	BPS-H80-031642	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, Mobile Unit 103	7912 West Ln Ste 221		Stockton	CA
CH09078AP	Active	BPS-H80-032276	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, Respite Center	201 N Stanislaus St Ste 101		Stockton	CA
CH09078AQ	Active	BPS-H80-034188	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, Mobile Unit 104	2650 Wigwam Drive, Unit 0		Stockton	CA
CH09078AR	Active	BPS-H80-034189	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, Mobile Unit 105	2650 Wigwam Drive, Unit 0		Stockton	CA
CH09078AS	Active	BPS-H80-035652	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, East Main	2524 E. Main Street		Stockton	CA
CH09078AT	Active	BPS-H80-035613	COMMUNITY MEDICAL CENTERS	Community Medical Centers, Vacaville Dental	600 Nut Tree Road, Ste. 120		Vacaville	CA
CH09078AU	Active	BPS-H80-035968	COMMUNITY MEDICAL CENTERS	Community Medical Centers, Weberstown Medical	87 W. March Lane, Ste.3		Stockton	CA
CH09078AV	Active	BPS-H80-037272	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, Vacaville Suite 210	600 Nut Tree Road STE 210		Vacaville	CA
CH09078AW	Active	BPS-H80-036625	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, CareLink Dental Van	2650 Wigwam Drive, Unit 0		Stockton	CA
CH09078AX	Active	BPS-H80-036647	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, TUSD Student Wellness Center	164 West Grant Line Road, Building 001 Portable Office /Room 8		Tracy	CA
CH09078AY	Active	BPS-H80-036972	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, CareLink Community Response Mobile Unit	2666 West Lane STE 700		Stockton	CA
CH09078AZ	Active	BPS-H80-039360	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, Lodi East	1150 S Cherokee Ln		Lodi	CA
CH09078BA	Active	BPS-H80-037615	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, CareLink Community Response Mobile Unit II	2666 West Lane STE 700		Stockton	CA
CH09078BB	Approved	BPS-H80-039597	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, CareLink Mammography Van	7210 Murray Dr		Stockton	CA
CH09078F	Active	BPS-H80-004978	Community Medical Centers, Inc.	Community Medical Centers, Tracy	730 N Central Ave		Tracy	CA
CH09078G	Active	BPS-H80-002964	Community Medical Centers, Inc.	Community Medical Centers, Dixon	131 W. A St.		Dixon	CA
CH09078H	Terminated	BPS-H80-006749	Community Medical Centers, Inc.	Community Medical Centers, Esparto	17050 S. Grafton St.		Esparto	CA
CH09078M	Active	BPS-H80-000928	Community Medical Centers, Inc.	Community Medical Centers, Lodi	2401 W. Turner Rd	Suite 450	Lodi	CA
CH09078N	Active	BPS-H80-002887	Community Medical Centers, Inc.	Community Medical Centers, Vacaville	600 Nut Tree Rd	Suite 310	Vacaville	CA
CH09078O	Terminated	BPS-H80-005741	Community Medical Centers, Inc.	Community Medical Centers, King	2640 E Lafayette St		Stockton	CA
CH09078P	Active	BPS-H80-006820	Community Medical Centers, Inc.	Community Medical Centers, Lawrence	721 Calaveras St		Lodi	CA
CH09078Q	Terminated	BPS-H80-000183	Community Medical Centers, Inc.	Community Medical Centers, Hammer	1721 E. Hammer Lane	STE A	Stockton	CA
CH09078R	Active	BPS-H80-008639	Community Medical Centers, Inc.	Community Medical Centers, Mariposa Road	2015 S. Mariposa Rd		Stockton	CA
CH09078S	Active	BPS-H80-008863	Community Medical Centers, Inc.	Community Medical Centers, Manteca	200 Cottage Ave		Manteca	CA
CH09078T	Terminated	BPS-H80-003514	Community Medical Centers, Inc.	Community Medical Centers, Mariposa Road	2003 E Mariposa Rd		Stockton	CA
CH09078U	Active	BPS-H80-008642	Community Medical Centers, Inc.	Community Medical Centers, Gleason House	423 S San Joaquin St		Stockton	CA
CH09078V	Active	BPS-H80-014346	Community Medical Centers, Inc.	Community Medical Centers, Waterloo	1031 Waterloo Rd.		Stockton	CA
CH09078W	Active	BPS-H80-015356	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, March Lane	1801 E. March Lane	D-470	Stockton	CA
CH09078X	Active	BPS-H80-017592	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, Dorothy L. Jones	2044 Fair St.		Stockton	CA
CH09078Y	Active	BPS-H80-019353	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, Weberstown	83 W. March Lane		Stockton	CA
CH09078Z	Active	BPS-H80-021441	COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, Tracy Dental	2135 N. Tracy Boulevard		Tracy	CA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH090780	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/01/2025
CH090780	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/01/2025
CH090780	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/01/2025
CH090780	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/01/2025
CH090780	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	04/01/2025
CH090780	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/01/2025
CH090780	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	01/01/2025
CH090780	ADVENTIST HEALTH LODI MEMORIAL	2415 W VINE ST STE 104B		LODI	CA	95242-3731	04/01/2020
CH090780	AMAZON PHARMACY #001	4500 S PLEASANT VALLEY RD STE 201		AUSTIN	TX	78744-2911	05/11/2020
CH090780	ANGKOR PHARMACY	4555 N PERSHING AVE STE 7		STOCKTON	CA	95207-6739	07/01/2016	08/19/2019
CH090780	AZ PHARMACY, LLC	DBA AMAZON PHARMACY #002	3809 E WATKINS ST	PHOENIX	AZ	85034	05/11/2020
CH090780	BIOPLUS SPECIALTY PHARMACY CA	7373 LINCOLN WAY		GARDEN GROVE	CA	92841	04/01/2025
CH090780	BIOPLUS SPECIALTY PHARMACY LA, LLC	2731 MANHATTAN BLVD STE B17		HARVEY	LA	70058	04/01/2025
CH090780	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	04/01/2025
CH090780	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	13925 YALE AVE STE 145		IRVINE	CA	92620-2670	04/01/2025
CH090780	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4740 VICTORY LN STE C	INDIANAPOLIS	IN	46203	04/01/2025
CH090780	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	145 S 79TH ST STE 70	CHANDLER	AZ	85226	04/01/2025
CH090780	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	04/01/2025
CH090780	BIOPLUS SPECIALTY PHARMACY, INC	3200 LAKE EMMA RD UNIT 1000		LAKE MARY	FL	32746	04/01/2025
CH090780	BJRX PHARMACY INC.	1801 E.MARCH LANE	SUITE:B280	STOCKTON	CA	95210	04/30/2012	03/27/2020
CH090780	CALMONT PHARMACY INC	2800 N CALIFORNIA ST STE9		STOCKTON	CA	95204-3758	04/01/2024
CH090780	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	01/01/2025
CH090780	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	01/01/2025
CH090780	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	01/01/2025
CH090780	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	01/01/2025
CH090780	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	01/01/2025
CH090780	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	01/01/2025
CH090780	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	01/01/2025
CH090780	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	01/01/2025
CH090780	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	01/01/2025
CH090780	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	01/01/2025
CH090780	CENTERWELL PHARMACY, INC.	9843 WINDISCH RD		WEST CHESTER	OH	45069	01/01/2023
CH090780	CENTERWELL PHARMACY, INC.	11010 FLORIDA CROWN DRIVE, SUITE 200		ORLANDO	FL	32824	01/01/2024
CH090780	CURANT HEALTH FLORIDA, LLC	11001 ROOSEVELT BLVD STE 1400		ST PETERSBURG	FL	33716-2338	04/01/2013
CH090780	CURANT HEALTH GEORGIA LLC	CURANT HEALTH	200 TECHNOLOGY CT SE BLDG 200 SUITE B	SMYRNA	GA	30082-5250	04/01/2013
CH090780	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	07/01/2025
CH090780	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	07/01/2025
CH090780	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	01/01/2025
CH090780	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	07/01/2025
CH090780	DIPLOMAT SPECIALTY PHARMACY	15211 VANOWEN ST	STE 301	VAN NUYS	CA	91405	10/01/2019	10/29/2021
CH090780	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	10/01/2019	06/04/2021
CH090780	DIPLOMAT SPECIALTY PHARMACY OF PHOENIX,	DIPLOMAT SPECIALTY PHARMACY	485 N. JUNIPER DR	CHANDLER	AZ	85226	10/01/2019	10/10/2021
CH090780	DIPLOMAT SPECIALTY PHARMACY OF SOUTHERN	DIPLOMAT SPECIALTY PHARMACY	1809 EXCISE AVENUE SUITE 204-208	ONTARIO	CA	91761	04/01/2019	08/01/2019
CH090780	DOGWOOD PHARMACY LLC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER RD STE K	GREENVILLE	SC	29607-6541	04/01/2025
CH090780	EL DORADO DRUG STORE	2005 S MARIPOSA RD		STOCKTON	CA	95205	04/01/2019	01/20/2023
CH090780	EL DORADO DRUG STORE	2005 S MARIPOSA RD		STOCKTON	CA	95205	04/01/2024
CH090780	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	04/01/2025
CH090780	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	04/01/2025
CH090780	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	04/01/2025
CH090780	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	04/01/2025
CH090780	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 05403	1175 W. LATHROP RD.	MANTECA	CA	95336	10/01/2017
CH090780	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16107	4707 PACIFIC AVE	STOCKTON	CA	95207	10/01/2017
CH090780	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16856	280 SPRECKELS AVE	MANTECA	CA	95336	10/01/2017
CH090780	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17412	16858 GOLDEN VALLEY PKWY	LATHROP	CA	95330	10/01/2017
CH090780	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16982	10424 TRINITY PARKWAY	STOCKTON	CA	95219	04/01/2019	01/16/2019
CH090780	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16294	2355 W KETTLEMAN LN	LODI	CA	95242	04/01/2019	01/16/2019
CH090780	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16274	3000 HARBISON DR	VACAVILLE	CA	95687	04/01/2019	01/16/2019
CH090780	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16223	2800 NAGLEE RD	TRACY	CA	95304	04/01/2019	01/16/2019
CH090780	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16223	2800 NAGLEE RD	TRACY	CA	95304	04/01/2019
CH090780	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16982	10424 TRINITY PARKWAY	STOCKTON	CA	95219	04/01/2019
CH090780	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16294	2355 W KETTLEMAN LN	LODI	CA	95242	04/01/2019
CH090780	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16274	3000 HARBISON DR	VACAVILLE	CA	95687	04/01/2019
CH09078F	HAROLD K REICH'S PHARMACY	REICH'S PHARMACY	39 W 10TH ST	TRACY	CA	95376-3901	01/10/2011	08/30/2019
CH090780	LA PHARMACY LLC	1048 S GARFIELD AVE	STE 101	ALHAMBRA	CA	91801	05/11/2020	04/13/2024
CH090780	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09147	2605 WEST MARCH LANE	STOCKTON	CA	95207	10/01/2015
CH090780	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09243	1000 W KETTLEMAN LN	LODI	CA	95240	10/01/2015
CH090780	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09261	100 W LODI AVE	LODI	CA	95240	10/01/2015
CH090780	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09830	6632 PACIFIC AVENUE	STOCKTON	CA	95207	10/01/2015
CH090780	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09916	5070 WEST LN	STOCKTON	CA	95210	10/01/2015	12/06/2022
CH090780	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 03908	1885 W 11TH ST	TRACY	CA	95376	07/01/2016
CH090780	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09855	3320 N TRACY BLVD	TRACY	CA	95376	07/01/2016
CH090780	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09950	1057 N 1ST ST	DIXON	CA	95620	07/01/2016
CH090780	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09866	1190 N MAIN ST	MANTECA	CA	95336	10/01/2017
CH090780	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09371	300 TRAVIS BLVD	FAIRFIELD	CA	94533	04/01/2019	01/16/2019
CH090780	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09819	191 DEPOT STREET	VACAVILLE	CA	95688	04/01/2019	01/16/2019
CH090780	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 03022	1063 C ST	GALT	CA	95632	04/01/2019	01/16/2019
CH090780	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09917	625 ELMIRA RD	VACAVILLE	CA	95687	04/01/2019	01/16/2019
CH090780	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09371	300 TRAVIS BLVD	FAIRFIELD	CA	94533	04/01/2019
CH090780	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09819	191 DEPOT STREET	VACAVILLE	CA	95688	04/01/2019
CH090780	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09917	625 ELMIRA RD	VACAVILLE	CA	95687	04/01/2019
CH090780	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 03022	1063 C ST	GALT	CA	95632	04/01/2019
CH090780	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09390	200 E HIGHWAY 12 STE D	VALLEY SPRINGS	CA	95252	10/01/2021
CH090780	LUCKY PHARMACY #783		777 E. MONTE VISTA AVE	VACAVILLE	CA	95688	07/05/2012	08/19/2019
CH090780	M.N. PHARMACY LLC	DBA AMAZON PHARMACY #003	6701 NW 7TH ST., STE. #199	MIAMI	FL	33126	05/11/2020
CH090780	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	05/11/2020
CH090780	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/13/2022
CH090780	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	05/11/2020
CH090780	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	05/11/2020
CH090780	OPTUM PHARMACY 806, INC.	2288 AUBURN BLVD	STE. 102	SACRAMENTO	CA	95821-1618	05/11/2020	02/02/2022
CH090780	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	10/01/2023
CH090780	OVERLAKE PHARMACY, LLC	4124 148TH AVE NE STE JA		REDMOND	WA	98052	05/11/2020	04/13/2024
CH090780	PILLPACK LLC	DBA PILLPACK BY AMAZON PHARMACY	250 COMMERCIAL ST STE 2012	MANCHESTER	NH	03101	05/11/2020
CH090780	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	01/01/2025
CH090780	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	01/01/2025
CH090780	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	01/01/2025
CH090780	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY	445 CASTRO STREET	SAN FRANCISCO	CA	94114	07/01/2025
CH090780	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	04/01/2025
CH090780	RALEY'S PHARMACY #305		2323 WEST HAMMER LANE	STOCKTON	CA	95209	07/01/2013	01/01/2019
CH090780	RALEY'S PHARMACY #306	4255 E. MORADA LANE		STOCKTON	CA	95212	07/01/2013
CH09078M	RALEY'S PHARMACY #445	311 SOUTH LOWER SACRAMENTO RD.		LODI	CA	95242	01/13/2011
CH090780	RALEY'S PHARMACY #445	311 SOUTH LOWER SACRAMENTO RD.		LODI	CA	95242	04/01/2019	08/29/2020
CH090780	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	04/01/2025
CH090780	S-MART PHARMACY #39		4725 QUAIL LAKES DR.	STOCKTON	CA	95207	01/01/2014	08/25/2020
CH090780	S-MART PHARMACY #91		7506 PACIFIC AVE.	STOCKTON	CA	95207	01/01/2014	02/01/2021
CH090780	SAFEWAY INC	SAFEWAY PHARMACY #2600	1801 WEST 11TH STREET	TRACY	CA	95376	10/01/2016	08/29/2020
CH090780	SAFEWAY INC	SAFEWAY PHARMACY #1109	2090 HARBISON DRIVE	VACAVILLE	CA	95687	10/01/2016
CH090780	SAFEWAY INC	SAFEWAY PHARMACY #1769	2808 COUNTRY CLUB BLVD	STOCKTON	CA	95204	10/01/2016
CH090780	SAFEWAY INC	SAFEWAY PHARMACY #1648	2449 W KETTLEMAN LANE	LODI	CA	95242	10/01/2016	08/29/2020
CH090780	SAFEWAY INC	SAFEWAY PHARMACY #1258	1235 STRATFORD AVENUE	DIXON	CA	95620	10/01/2016
CH090780	SAFEWAY INC	SAFEWAY PHARMACY #2707	6445 N PACIFIC AVE	STOCKTON	CA	95207	10/01/2016	08/29/2020
CH090780	SAFEWAY INC	SAFEWAY PHARMACY #3124	1187 S MAIN ST	MANTECA	CA	95337-5747	10/01/2016
CH09078G	SAFEWAY INC	SAFEWAY PHARMACY #1258	1235 STRATFORD AVENUE	DIXON	CA	95620	10/07/2011
CH090780	SAFEWAY INC	SAFEWAY PHARMACY #2600	1801 WEST 11TH STREET	TRACY	CA	95376	10/01/2023
CH090780	SANTA BARBARA SPECIALTY PHARMACY LLC	4690 CARPINTERIA AVE STE B		CARPINTERIA	CA	93013	04/01/2025
CH090780	SMART PHARMACY #209		610 WEST KETTLEMAN LANE	LODI	CA	95240	01/01/2014	02/01/2021
CH090780	THRIFTY PAYLESS INC.	RITE AID #6004	900 NORTH MAIN STREET	MANTECA	CA	95336	10/01/2015	11/09/2016
CH090780	THRIFTY PAYLESS, INC.	RITE AID #5996	1050 NORTH WILSON WAY	STOCKTON	CA	95205	10/01/2015
CH090780	THRIFTY PAYLESS, INC.	RITE AID #6510	4774 WEST LANE	STOCKTON	CA	95210	10/01/2015	06/12/2025
CH090780	THRIFTY PAYLESS, INC.	RITE AID #6005	1245 WEST YOSEMITE AVENUE	MANTECA	CA	95337	10/01/2015
CH090780	THRIFTY PAYLESS, INC.	RITE AID #6291	1970 WEST GRANTLINE ROAD	TRACY	CA	95376	10/01/2015
CH090780	THRIFTY PAYLESS, INC.	RITE AID #5998	6455 PACIFIC AVENUE	STOCKTON	CA	95207	10/01/2015
CH090780	THRIFTY PAYLESS, INC.	RITE AID #6490	599 E VALPICO ROAD	TRACY	CA	95376	10/01/2015	12/01/2021
CH090780	THRIFTY PAYLESS, INC.	RITE AID #6000	520 WEST LODI AVENUE	LODI	CA	95240	01/01/2019
CH090780	THRIFTY PAYLESS, INC.	RITE AID #6512	1000 W MONTE VISTA AVENUE	TURLOCK	CA	95382	01/01/2021	03/01/2023
CH090780	THRIFTY PAYLESS, INC.	RITE AID #6434	1710 CALIFORNIA ST RITE AID 6434	ESCALON	CA	95320	01/01/2021	06/28/2024
CH090780	TRUEPILL	3121 DIABLO AVE		HAYWARD	CA	94545	05/11/2020	04/13/2024
CH090780	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/01/2017
CH090780	WAL-MART PHARMACY 10-1554	3223 EAST HAMMER LANE		STOCKTON	CA	95212	04/01/2013
CH090780	WAL-MART PHARMACY 10-1704	1501 HELEN POWER DRIVE		VACAVILLE	CA	95687	04/01/2013
CH090780	WAL-MART PHARMACY 10-1789	1601 S. LOWER SACRAMENTO RD.		LODI	CA	95242	04/01/2013
CH090780	WAL-MART PHARMACY 10-1840	1205 S. MAIN STREET		MANTECA	CA	95337	04/01/2013
CH090780	WAL-MART PHARMACY 10-2025	3010 WEST GRANT LINE ROAD		TRACY	CA	95304	04/01/2013
CH090780	WAL-MART PHARMACY 10-3022	1189 E MARCH LANE		STOCKTON	CA	95210	04/01/2019
CH090780	WAL-MART PHARMACY 10-5139	235 E DORSET DR		DIXON	CA	95620	04/01/2013
CH090780	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/01/2017
CH090780	WALGREEN CO	DBA: WALGREENS #10482	7850 WEST LANE	STOCKTON	CA	95210	07/02/2012
CH090780	WALGREEN CO	DBA: WALGREENS #10631	14780 S HARLAN RD	LATHROP	CA	95330	07/02/2012
CH090780	WALGREEN CO.	DBA: WALGREENS # 02434	1830 WEST 11TH ST.	TRACY	CA	95376	07/02/2012
CH090780	WALGREEN CO.	DBA: WALGREENS # 02644	2010 ALAMO DRIVE	VACAVILLE	CA	95687	07/02/2012
CH090780	WALGREEN CO.	DBA: WALGREENS #13984	1528 E FREMONT ST	STOCKTON	CA	95205	07/02/2012
CH090780	WALGREEN CO.	DBA: WALGREENS # 02680	15 W HARDING WAY	STOCKTON	CA	95204	07/02/2012
CH090780	WALGREEN CO.	DBA: WALGREENS # 02770	7929 LOWER SACRAMENTO RD.	STOCKTON	CA	95210	07/02/2012
CH090780	WALGREEN CO.	DBA: WALGREENS # 02961	75 NORTH HAM LANE	LODI	CA	95242	07/02/2012
CH090780	WALGREEN CO.	DBA: WALGREENS # 04107	10 WEST MAIN ST.	WOODLAND	CA	95695	07/02/2012
CH090780	WALGREEN CO.	DBA: WALGREENS #15398	660 W. MARCH LANE	STOCKTON	CA	95207	07/02/2012
CH090780	WALGREEN CO.	DBA: WALGREENS # 09716	102 N JACK TONE RD	RIPON	CA	95366-9514	07/02/2012
CH090780	WALGREEN CO.	DBA: WALGREENS # 10454	1071 N MAIN ST	MANTECA	CA	95336	07/02/2012
CH090780	WALGREEN CO.	DBA: WALGREENS #10766	2810 S TRACY BLVD	TRACY	CA	95377	01/01/2014
CH090780	WALGREEN CO.	DBA: WALGREENS #09723	3131 W. HAMMER LANE	STOCKTON	CA	95209-2747	01/01/2014
CH090780	WALGREEN CO.	DBA: WALGREENS #12549	2040 E. MARIPOSA RD.	STOCKTON	CA	95205-7736	01/01/2014
CH090780	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #15987	1020 29TH ST STE 140	SACRAMENTO	CA	95816	07/01/2025
CH090780	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	07/01/2013	07/22/2015
CH090780	WALGREENS MAIL SERVICE, INC.		8337 S PARK CIRCLE	ORLANDO	FL	32819-9049	07/01/2013	07/22/2015
CH090780	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	07/01/2025
CH090780	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/01/2025
CH090780	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	07/01/2025
CH090780	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	07/01/2023
CH090780	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	2/23/2024 9:01:37 PM	2/21/2025 3:18:37 PM	2/21/2025 3:18 PM
Contacts	Authorizing Official	Update	Group Change Request	Noguera, Christine CEO Community Medical Centers, Inc. 2093732826	Diederich, Greg CEO Community Medical Centers, inc. 2093732826	11/20/2024 8:03 AM
Details	Last Recertification Date	Update	Recertification	2/22/2023 2:03:59 PM	2/23/2024 9:01:37 PM	2/23/2024 9:01 PM
Contacts	Primary Contact	Update	OPA Edit	Hui, Pak Director of Pharmacy Community Medical Centers, Inc. 2095650517	Hui, Pak Director of Pharmacy Community Medical Centers, Inc. 2099404677	12/29/2023 1:56 PM
Contacts	Authorizing Official	Update	OPA Edit	Noguera, Christine C CEO Community Medical Centers, Inc. 5599607779	Noguera, Christine CEO Community Medical Centers, Inc. 2093732826	12/29/2023 1:56 PM
Contacts	Primary Contact	Update	OPA Edit	Hui, Pak Director of Pharmacy Community Medical Centers, Inc. 2099404677	Hui, Pak Director of Pharmacy Community Medical Centers, Inc. 2095650517	8/9/2023 3:41 PM
Contacts	Authorizing Official	Update	OPA Edit	Noguera, Christine CEO Community Medical Centers, Inc. 2093732826	Noguera, Christine C CEO Community Medical Centers, Inc. 5599607779	8/9/2023 3:41 PM
Details	Last Recertification Date	Update	Recertification	2/25/2022 3:15:28 PM	2/22/2023 2:03:59 PM	2/22/2023 2:03 PM
Details	Last Recertification Date	Update	Recertification	2/8/2021 4:23:58 PM	2/25/2022 3:15:28 PM	2/25/2022 3:15 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1710009659	2/8/2021 4:23 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	2/8/2021 4:23 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	2/8/2021 4:23 PM
Details	Last Recertification Date	Update	Recertification	2/4/2020 12:58:26 PM	2/8/2021 4:23:58 PM	2/8/2021 4:23 PM
Contacts	Primary Contact	Update	Profile Change Request	Hui, Pak Pharmacist in Charge Community Medical Centers, Inc. 2099404677	Hui, Pak Director of Pharmacy Community Medical Centers, Inc. 2099404677	12/21/2020 8:25 PM
Details	Last Recertification Date	Update	Recertification	2/19/2019 8:52:39 PM	2/4/2020 12:58:26 PM	2/4/2020 12:58 PM
Details	Last Recertification Date	Update	Recertification	2/21/2018 10:09:49 AM	2/19/2019 8:52:39 PM	2/19/2019 8:52 PM
Addresses	Main Address	Update	Recertification	2401 W Turner Rd Suite 450 Lodi, CA 95242-2191	2401 W. Turner Rd Suite 450 Lodi, CA 95242-2191	2/21/2018 10:09 AM
Details	Last Recertification Date	Update	Recertification	2/6/2017 12:00:00 AM	2/21/2018 10:09:49 AM	2/21/2018 10:09 AM
Contacts	Authorizing Official	Update	New Registration	Noguera, Christine CEO 2093732826	Noguera, Christine CEO Community Medical Centers, Inc. 2093732826	10/16/2017 11:45 AM
Contacts	Primary Contact	Update		Hui, Pak Pharmacist in Charge 2099404677	Hui, Pak Pharmacist in Charge Community Medical Centers, Inc. 2099404677	10/12/2017 11:46 AM
Contacts	Authorizing Official	Update		Noguera, Christine CEO 2093732826	Noguera, Christine CEO 2093732826	7/18/2017 4:46 PM
Contacts	Primary Contact	Update		Hui, Pak Pharmacist in Charge 2099404677	Hui, Pak Pharmacist in Charge 2099404677	2/6/2017 2:30 PM
Addresses	Main Address	Insert			2401 W Turner Rd Suite 450 Lodi, CA 95242-2191	2/6/2017 2:28 PM
Details	Last Recertification Date	Update		3/2/2016 12:00:00 AM	2/6/2017 12:00:00 AM	2/6/2017 2:28 PM
Contacts	Authorizing Official	Update		Haskins, Sandy Acting CEO 2093732826	Noguera, Christine CEO 2093732826	1/11/2017 8:52 PM
Contacts	Primary Contact	Insert			Hui, Pak Pharmacist in Charge 2099404677	3/7/2016 8:51 AM
Details	Last Recertification Date	Update		3/4/2015 12:00:00 AM	3/2/2016 12:00:00 AM	3/3/2016 7:07 PM
Addresses	Billing Address	Update		COMMUNITY MEDICAL CENTERS, INC PO BOX 779 STOCKTON, CA 95201-0779	Community Medical Centers, Inc. PO Box 779 Stockton, CA 95201-0779	7/29/2015 1:15 PM
Details	Entity Name	Update		COMMUNITY MEDICAL CENTERS, INC.	Community Medical Centers, Inc.	7/29/2015 1:15 PM
Details	Entity Subname	Update		Woodbridge Medical Group	Community Medical Centers, Lodi	7/29/2015 1:15 PM
Addresses	Billing Address	Insert			COMMUNITY MEDICAL CENTERS, INC PO BOX 779 STOCKTON, CA 95201-0779	7/29/2015 1:15 PM
Details	Last Recertification Date	Update		3/13/2014 12:00:00 AM	3/4/2015 12:00:00 AM	3/4/2015 2:01 PM
Details	Entity Subname	Update		COMMUNITY MEDICAL CENTERS, LODI	Woodbridge Medical Group	1/23/2015 9:17 AM
Details	Entity Subname	Update		WOODBRIDGE MEDICAL GROUP	COMMUNITY MEDICAL CENTERS, LODI	1/23/2015 9:14 AM
Contacts	Authorizing Official	Insert			Haskins, Sandy Acting CEO 2093732826	4/30/2014 10:39 AM
Details	Last Recertification Date	Update		4/1/2013 12:00:00 AM	3/13/2014 12:00:00 AM	3/13/2014 10:04 PM
Details	Entity Name	Update		COMMUNITY MEDICAL CENTERS, INC	COMMUNITY MEDICAL CENTERS, INC.	3/13/2014 10:04 PM
Details	Last Recertification Date	Update			4/1/2013 12:00:00 AM	3/11/2013 9:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/14/2013 6:47 AM
Medicaid Billing	Medicaid: Number	Insert			FHC70460F	1/14/2013 6:47 AM
Medicaid Billing	Medicaid: State	Insert			CA	1/14/2013 6:47 AM
Medicaid Billing	NPI: Number	Insert			1881685964	1/14/2013 6:47 AM
Details	Last Recertification Date	Insert				9/5/2006 4:30 PM
Details	Grant Number	Insert			H80CS00138	9/5/2006 4:30 PM
Details	340B ID	Insert			CH09078M	9/5/2006 4:30 PM
Details	Is Authorizing Official EHB Data	Insert				9/5/2006 4:30 PM
Dates	Last Date That 340B Drugs Purchased	Insert				9/5/2006 4:30 PM
Details	Medicare Provider Number	Insert				9/5/2006 4:30 PM
Details	Entity Name	Insert			COMMUNITY MEDICAL CENTERS, INC	9/5/2006 4:30 PM
Details	Program Code	Insert			CH	9/5/2006 4:30 PM
Details	Entity Subname	Insert			WOODBRIDGE MEDICAL GROUP	9/5/2006 4:30 PM
Dates	Participating Approval Date	Insert			9/5/2006 12:00:00 AM	9/5/2006 4:30 PM
Details	State	Insert			Active	9/5/2006 4:30 PM
Dates	Registration Date	Insert			9/5/2006 12:00:00 AM	9/5/2006 4:30 PM
Dates	Signed By Date	Insert			6/20/2006 12:00:00 AM	9/5/2006 4:30 PM
Dates	Start Date	Insert			10/1/2006 12:00:00 AM	9/5/2006 4:30 PM
Terminations	Termination Comments	Insert				9/5/2006 4:30 PM
Terminations	Termination Date	Insert				9/5/2006 4:30 PM
Terminations	Termination Effective Date	Insert				9/5/2006 4:30 PM
Terminations	Termination Reason	Insert				9/5/2006 4:30 PM

340B Drug Pricing Program Database