Covered Entity Details

CH09016B EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER (Active) - information as of 5/5/2025 11:48:49 PM

Main Details

Name

EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER

Subdivision Name

EL RIO OB/GYN ASSOCIATES

Type

HRSA-Funded Health Center

Site ID

BPS-H80-001850

340B ID

CH09016B

Grant Number

H80CS00230

Additional Details

Current Program Status

Active

Registration Date

5/18/2008

Participating Start Date

7/1/2008

Participating Approval Date

6/5/2008

Last Recertification Date

2/11/2025

Contacts

Authorizing Official

El RIo Health
Clinton Kuntz, CEO
(520) 670-3909

Primary Contact

El Rio Santa Cruz Neighborhood Health Center
Ocie Wilson, Pharmacy Director
(520) 309-3923

Addresses

Street Address

225 WEST IRVINGTON RD
TUCSON, AZ 85714

Billing Address

EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER
450 W Paseo Redondo
TUCSON, AZ, AZ 85701

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

Comments

Comment	Last Updated On
5/4/12 - Added NPI #'s, changed sub-division name and AO and contact phone #.	05/04/2012

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
AZ	947978	1932490109

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	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06766	1880 E IRVINGTON ROAD	TUCSON	AZ	85714-1754	10/11/2023	01/01/2024			01/01/2024

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH090160	Active	BPS-H80-001464	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER	839 WEST CONGRESS ST	TUCSON	AZ
CH09016A	Active	BPS-H80-003194	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER	EL RIO SOUTHWEST MEDICAL	1500 W COMMERCE CT	TUCSON	AZ
CH09016AC	Active	BPS-H80-003194	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER	EL RIO SOUTHWEST DENTAL	1500 W COMMERCE CT	TUCSON	AZ
CH09016AD	Active	BPS-H80-014116	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER	EL RIO NORTHWEST DENTAL	340 W Prince Rd	TUCSON	AZ
CH09016AE	Terminated	BPS-H80-013833	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER, INC.	EL RIO CLINIC AT CODAC BEHAVIORAL HEALTH EAST	630 N ALVERNON WAY	TUCSON	AZ
CH09016AF	Terminated	BPS-H80-014393	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER, INC.	St. Elizabeth's Health Center	140 W SPEEDWAY BLVD	TUCSON	AZ
CH09016AG	Active	BPS-H80-018677	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER, INC.	Health On Broadway	1 W. Broadway Blvd	Tucson	AZ
CH09016AH	Active	BPS-H80-029634	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER, INC.	HealthOn University	434 E University Blvd	Tucson	AZ
CH09016AJ	Active	BPS-H80-032792	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CE	El Rio Health Center of Opportunity	4550 S Palo Verde Rd	Tucson	AZ
CH09016AK	Active	BPS-H80-033565	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CE	El Rio Health - Grant Health Center	3655 E Grant Rd	Tucson	AZ
CH09016AL	Active	BPS-H80-035301	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CE	El Rio Health Abrams Health Center	3950 S Country Club Rd STE 130	Tucson	AZ
CH09016AM	Active	BPS-H80-036016	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CE	University Health Center	434 E. University Blvd. STE 200	Tucson	AZ
CH09016B	Active	BPS-H80-001850	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER	EL RIO OB/GYN ASSOCIATES	225 WEST IRVINGTON RD	TUCSON	AZ
CH09016E	Active	BPS-H80-027263	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER	EL RIO CHERRYBELL Health Center	1230 S. Cherrybell Stravenue	TUCSON	AZ
CH09016F	Active	BPS-H80-013831	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER, INC.	El Rio Pascua Yaqui	7490 S CAMINO DE OESTE	TUCSON	AZ
CH09016O	Terminated	BPS-H80-003978	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER	EL Rio Broadway Clinic	1101 EAST BROADWAY BLVD	TUCSON	AZ
CH09016P	Active	BPS-H80-001347	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER	EL RIO NORTHWEST CLINIC	320 W. PRINCE RD	TUCSON	AZ
CH09016S	Terminated	BPS-H80-004706	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER	ST. MARY'S HOSPITAL WOUND CLINIC	1802 W SAINT MARYS RD	TUCSON	AZ
CH09016T1	Active	BPS-H80-000328	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER	EL PUEBLO HEALTH CENTER	101 WEST IRVINGTON ROAD	TUCSON	AZ
CH09016U	Terminated	BPS-H80-010541	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER	TUCSON BIRTH AND WOMEN'S HEALTH CENTER	5979 East Grant Road	TUCSON	AZ
CH09016Y	Active	BPS-H80-009093	EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER	SOUTHEAST CLINIC	6950 E. GOLFLINKS ROAD	TUCSON	AZ

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH090160	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	01/01/2025
CH090160	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	01/01/2025
CH090160	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	01/01/2025
CH090160	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	01/01/2025
CH090160	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	01/01/2025
CH090160	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	01/01/2025
CH090160	ALBERTSON'S LLC	OSCO DRUG #2988	5085 N LA CANADA DRIVE	TUCSON	AZ	85704	04/01/2020
CH090160	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09254	240 W CONTINENTAL RD	GREEN VALLEY	AZ	85622	04/01/2020
CH090160	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09272	7499 E. BROADWAY	TUCSON	AZ	85710	04/01/2020
CH090160	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09277	6895 E. SUNRISE	TUCSON	AZ	85750	04/01/2020
CH090160	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09273	3785 WEST INA RD.	TUCSON	AZ	85741	04/01/2020
CH090160	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09232	4748 E. SUNRISE DRIVE	TUCSON	AZ	85718	04/01/2020
CH090160	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09211	6488 N. ORACLE ROAD	TUCSON	AZ	85704	04/01/2020
CH090160	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09274	615 N. ALVERNON	TUCSON	AZ	85711	04/01/2020
CH090160	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09336	7901 E. GOLF LINKS ROAD	TUCSON	AZ	85730	04/01/2020
CH090160	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09302	8920 E TANQUE VERDE	TUCSON	AZ	85749	04/01/2020
CH090160	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09207	865 E. GRANT	TUCSON	AZ	85719	04/01/2020	06/22/2022
CH090160	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09374	1900 W. VALENCIA RD.	TUCSON	AZ	85746	07/01/2020
CH09016A	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09374	1900 W. VALENCIA RD.	TUCSON	AZ	85746	01/01/2024
CH090160	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2015	02/01/2021
CH090160	AVELLA OF DEER VALLEY, INC. #38	DBA AVELLA SPECIALTY PHARMACY	24416 N. 19TH AVE	PHOENIX	AZ	85085	04/01/2017	02/01/2021
CH090160	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	07/01/2018	02/01/2021
CH090160	AVELLA OF TUCSON	4512 E CAMP LOWELL DR		TUCSON	AZ	85712-1282	10/01/2015	01/26/2018
CH090160	BIOPLUS SPECIALTY PHARMACY, INC	3200 LAKE EMMA RD UNIT 1000		LAKE MARY	FL	32746	07/01/2022
CH090160	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/01/2021
CH090160	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/01/2021
CH090160	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/01/2021
CH090160	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/01/2021
CH090160	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/01/2021
CH090160	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/01/2021
CH090160	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/01/2021
CH090160	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/01/2021
CH090160	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/01/2021
CH09016AG	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	01/01/2024
CH090160	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/01/2021
CH09016AC	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	01/01/2024
CH090160	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	07/01/2021
CH090160	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	07/01/2021
CH090160	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/01/2021
CH090160	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	01/01/2020
CH090160	FRY'S PHARMACY #083	1795 W VALENCIA RD		TUCSON	AZ	85746	04/01/2020
CH090160	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY # 11339	777 S. HARBOR BLVD., SUITE E-164	LA HABRA	CA	90631	01/01/2023	01/01/2023
CH090160	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY # 11339	777 S. HARBOR BLVD., SUITE E-164	LA HABRA	CA	90631	10/01/2023
CH090160	GENOA HEALTHCARE LLC	1075 E FORT LOWELL RD		TUCSON	AZ	85719	07/01/2021
CH090160	GENOA HEALTHCARE LLC	4631 S POWER ROAD	BUILDING A, SUITE 105	MESA	AZ	85212	07/01/2021
CH090160	GENOA HEALTHCARE LLC	1642 S PRIEST DR	BLDG 6, STE 101	TEMPE	AZ	85281	07/01/2021
CH090160	GENOA HEALTHCARE LLC	1101 NORTH CENTRAL AVE	STE 102	PHOENIX	AZ	85004	12/20/2021
CH090160	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 07867	5100 E. GRANT RD.	TUCSON	AZ	85712	04/01/2020
CH090160	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 07841	4365 N ORACLE RD	TUCSON	AZ	85705	04/01/2020
CH090160	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 07876	3832 EAST SPEEDWAY	TUCSON	AZ	85716	04/01/2020
CH090160	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 07855	2601 S. HOUGHTON RD.	TUCSON	AZ	85730	04/01/2020
CH090160	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 07859	6370 N. CAMPBELL AVE., #120	TUCSON	AZ	85718	04/01/2020
CH090160	GERMAN DOBSON CVS, L.L.C.	CVS PHARMACY # 17223	4040 N ORACLE RD	TUCSON	AZ	85705	04/01/2020
CH090160	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 08420	7740 N CORTARO RD	TUCSON	AZ	85743	04/01/2020
CH090160	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 00091	8705 E SPEEDWAY BLVD	TUCSON	AZ	85710	04/01/2020	08/11/2022
CH090160	GERMAN DOBSON CVS, L.L.C.	CVS PHARMACY # 16217	10555 N ORACLE RD	ORO VALLEY	AZ	85737	04/01/2020
CH090160	GERMAN DOBSON CVS, L.L.C.	DBA CVS/PHARMACY # 10307	6310 E. BROADWAY BLVD.	TUCSON	AZ	85710	04/01/2020
CH090160	GERMAN DOBSON CVS, L.L.C.	CVS PHARMACY # 16772	3699 E BROADWAY BLVD	TUCSON	AZ	85716	04/01/2020
CH090160	GERMAN DOBSON CVS, L.L.C.	CVS PHARMACY # 16659	1225 W IRVINGTON RD	TUCSON	AZ	85714	04/01/2020
CH090160	GERMAN DOBSON CVS, L.L.C.	CVS PHARMACY # 16296	6500 E GRANT RD	TUCSON	AZ	85715	04/01/2020
CH090160	GERMAN DOBSON CVS, L.L.C.	CVS/PHARMACY #10742	2385 N. SILVERBELL ROAD	TUCSON	AZ	85745	04/01/2020
CH090160	GERMAN DOBSON CVS, L.L.C.	DBA CVS/PHARMACY # 10184	825 EAST UNIVERSITY BLVD., SUITE 101	TUCSON	AZ	85719	04/01/2020
CH090160	GERMAN DOBSON CVS, L.L.C.	CVS PHARMACY # 16983	9615 E OLD SPANISH TRL	TUCSON	AZ	85748	04/01/2020
CH090160	GERMAN DOBSON CVS, L.L.C.	DBA CVS/PHARMACY # 10006	10650 NORTH ORACLE RD	ORO VALLEY	AZ	85737	04/01/2020
CH090160	GERMAN DOBSON CVS, L.L.C.	CVS PHARMACY # 16295	3901 W INA RD	TUCSON	AZ	85741	04/01/2020
CH090160	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05026	1212 S. GREENFIELD RD.	MESA	AZ	85206	07/01/2021
CH090160	GERMAN DOBSON CVS, L.L.C.	CVS/PHARMACY #10616	7547 E. SOUTHERN AVE.	MESA	AZ	85209	01/01/2023	01/01/2023
CH090160	GERMAN DOBSON CVS, L.L.C.	CVS PHARMACY # 16220	4151 E HIGHWAY 90	SIERRA VISTA	AZ	85635	10/01/2023
CH090160	GERMAN DOBSON CVS, L.L.C.	CVS/PHARMACY #10616	7547 E. SOUTHERN AVE.	MESA	AZ	85209	10/01/2023
CH09016AH	GERMAN DOBSON CVS, L.L.C.	CVS/PHARMACY #10742	2385 N. SILVERBELL ROAD	TUCSON	AZ	85745	01/01/2024
CH09016AJ	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 07841	4365 N ORACLE RD	TUCSON	AZ	85705	01/01/2024
CH090160	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03662	5357 EHRLICH RD	TAMPA	FL	33625	04/01/2024
CH090160	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03174	1370 WEST MAIN STREET	NEWARK	OH	43055	07/01/2021
CH090160	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03314	4240 PEARL RD	CLEVELAND	OH	44109	01/01/2023	01/01/2023
CH090160	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03314	4240 PEARL RD	CLEVELAND	OH	44109	10/01/2023	01/11/2024
CH090160	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	01/01/2020	10/23/2020
CH090160	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	01/01/2020
CH090160	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	01/01/2022
CH090160	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	01/01/2022
CH090160	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	07/24/2020
CH090160	OPTUM PHARMACY 805, INC	1101 N CENTRAL AVE, STE 102		PHOENIX	AZ	85004-1829	07/24/2020
CH090160	OPTUM PHARMACY 806, INC.	2288 AUBURN BLVD	STE. 102	SACRAMENTO	CA	95821-1618	10/01/2020	10/15/2021
CH090160	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	01/01/2020	10/01/2022
CH090160	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/01/2021
CH090160	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/01/2021
CH090160	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/01/2021
CH090160	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	07/01/2021
CH090160	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #3129	1002 EAST MCDOWELL ROAD	PHOENIX	AZ	85006	04/01/2024
CH090160	SAFEWAY INC	SAFEWAY PHARMACY #0267	2940 W. VALENCIA ROAD	TUCSON	AZ	85746	04/01/2020
CH090160	SAFEWAY INC	SAFEWAY PHARMACY #0255	1551 W ST MARYS RD	TUCSON	AZ	85745	04/01/2020
CH090160	SAFEWAY INC	SAFEWAY PHARMACY #1684	1940 E BROADWAY BLVD	TUCSON	AZ	85719	04/01/2020
CH090160	SMITH'S FOOD & DRUG	DBA FRY'S FOOD & DRUG #17	4150 E. 22ND STREET	TUCSON	AZ	85711	04/01/2020
CH090160	SMITH'S FOOD & DRUG CTRS	DBA FRY'S FOOD AND DRUG #131	2480 NORTH SWAN ROAD	TUCSON	AZ	85712	04/01/2020
CH090160	SMITH'S FOOD & DRUG CTRS	FRY'S FOOD AND DRUG #137	7050 EAST 22ND STREET	TUCSON	AZ	85710	04/01/2020
CH090160	SMITH'S FOOD AND DRUG	DBA FRY'S FOOD AND DRUG #138	4036 N. 1ST STREET	TUCSON	AZ	85719	04/01/2020
CH090160	SMITHS FOOD & DRUG CENTER	DBA FRYS FOOD & DRUG #20	3640 S 16 AVENUE	TUCSON	AZ	85713	04/01/2020
CH090160	SMITHS FOOD & DRUG CENTERS	DBA FRYS FOOD & DRUG #21	555 E GRANT ROAD	TUCSON	AZ	85705	04/01/2020
CH090160	SMITHS FOOD & DRUG CENTERS	DBA FRYS FOOD & DRUG #34	7812 E. SPEEDWAY	TUCSON	AZ	85710	04/01/2020
CH090160	SMITHS FOOD & DRUG CENTERS	DBA FRYS FOOD & DRUG #57	7870 N SILVERBELL ROAD	MARANA	AZ	85743	04/01/2020
CH090160	SMITHS FOOD & DRUG CENTERS	DBA FRYS FOOD & DRUG #42	9401 E 22 STREET	TUCSON	AZ	85710	04/01/2020
CH090160	SMITHS FOOD & DRUG CENTERS	DBA FRYS FOOD & DRUG #58	2001 E IRVINGTON ROAD	TUCSON	AZ	85714	04/01/2020
CH090160	SMITHS FOOD & DRUG CENTERS	DBA FRYS PHARMACY #36	3770 W INA ROAD	TUCSON	AZ	85741	04/01/2020
CH090160	SMITHS FOOD & DRUG CENTERS	DBA FRYS FOOD & DRUG #33	7050 E GOLF LINKS	TUCSON	AZ	85730	04/01/2020
CH090160	SMITHS FOOD AND DRUG CENTERS INC.	DBA: FRY'S FOOD STRORES OF AZ #679	15950 SOUTH RANCHO SAHUARITA BLVD	SAHUARITA	AZ	85629	04/01/2020
CH090160	SMITHS FOOD AND DRUG CENTERS INC.	DBA:FRY'S FOOD STORES OF AZ #689	12100 N THORNYDALE RD	MARANA	AZ	85653	04/01/2020
CH090160	THOMAS PHOENIX CVS, L.L.C.	DBA: CVS/PHARMACY # 03625	8245 W. THOMAS RD.	PHOENIX	AZ	85033	07/01/2022
CH090160	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/01/2020
CH090160	WAL-MART PHARMACY # 10-4473	2175 WEST RUTHRAUFF ROAD		TUCSON	AZ	85705	04/01/2020
CH090160	WAL-MART PHARMACY 10-1291	7150 EAST SPEEDWAY		TUCSON (E)	AZ	85710	04/01/2020
CH090160	WAL-MART PHARMACY 10-1325	455 EAST WETMORE		TUCSON (N)	AZ	85705	04/01/2020
CH090160	WAL-MART PHARMACY 10-1612	1650 WEST VALENCIA		TUCSON	AZ	85746	04/01/2020
CH090160	WAL-MART PHARMACY 10-3049	2550 S. KOLB RD.		TUCSON	AZ	85710	04/01/2020
CH090160	WAL-MART PHARMACY 10-3143	8640 E BROADWAY		TUCSON	AZ	85710	04/01/2020
CH090160	WAL-MART PHARMACY 10-3357	3925 EAST GRANT ROAD		TUCSON(ALVERNON)	AZ	85712	04/01/2020
CH090160	WAL-MART PHARMACY 10-3377	2823 WEST VALENCIA ROAD		TUSCON (CARDINAL)	AZ	85746	04/01/2020
CH090160	WAL-MART PHARMACY 10-3884	3435 E. BROADWAY BLVD		TUCSON	AZ	85716	04/01/2020
CH090160	WAL-MART PHARMACY 10-4603	5500 E. 22ND ST.		TUCSON	AZ	85711	04/01/2020
CH090160	WAL-MART PHARMACY 10-5626	1260 E. TUSCON MKT		TUSCON	AZ	85713	04/01/2020
CH090160	WAL-MART PHARMACY 10-5858	9260 S. HOUGHTON RD		TUCSON	AZ	85747	04/01/2020
CH090160	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/01/2020
CH090160	WALGREEN ARIZONA DRUG CO	DBA:WALGREENS #15363	4655 E. SUNRISE DR.	TUCSON	AZ	85718	01/01/2024
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 02851	7000 N 16TH ST	PHOENIX	AZ	85020	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 02232	313 W ESPERANZA BLVD	GREEN VALLEY	AZ	85614	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05312	375 W CONTINENTAL RD	GREEN VALLEY	AZ	85622	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 09186	18600 S NOGALES HWY	GREEN VALLEY	AZ	85614	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07623	1959 N GRAND AVE	NOGALES	AZ	85621-1341	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05027	1950 E FRY BLVD	SIERRA VISTA	AZ	85635	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS #10684	13542 E COLOSSAL CAVE RD	VAIL	AZ	85641	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 02372	7114 NORTH ORACLE	TUCSON	AZ	85704	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03463	1415 W RIVER RD	TUCSON	AZ	85704	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 02451	4220 N ORACLE RD	TUCSON	AZ	85705-1632	10/12/2012	11/10/2022
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 04104	2411 N. ORACLE ROAD	TUCSON	AZ	85705	10/12/2012	08/20/2015
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06491	1351 W PRINCE ROAD	TUCSON	AZ	85705	10/12/2012	02/24/2025
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07463	525 W VALENCIA ROAD	TUCSON	AZ	85706-7636	10/12/2012	11/07/2024
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 02910	8730 E BROADWAY BLVD	TUCSON	AZ	85710	10/12/2012	02/28/2024
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 04102	6767 E. BROADWAY BLVD.	TUCSON	AZ	85710	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 09953	7885 E SPEEDWAY BLVD	TUCSON	AZ	85710-1626	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03856	5480 E 22ND STREET	TUCSON	AZ	85711-5406	10/12/2012	03/09/2020
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05892	3910 E 22ND STREET	TUCSON	AZ	85711	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06244	4700 E BROADWAY BLVD	TUCSON	AZ	85711	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 04045	4685 E GRANT RD	TUCSON	AZ	85712	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 04764	5455 E SPEEDWAY BLVD	TUCSON	AZ	85712	10/12/2012	02/21/2024
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07203	2415 N ALVERNON WAY	TUCSON	AZ	85712-2501	10/12/2012	08/20/2015
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03377	1900 S 6TH AVE	TUCSON	AZ	85713	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06953	605 W AJO WAY	TUCSON	AZ	85713-6047	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06766	1880 E IRVINGTON ROAD	TUCSON	AZ	85714-1754	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 11183	3200 E SPEEDWAY	TUCSON	AZ	85716	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03249	4910 NORTH FIRST AVE	TUCSON	AZ	85718	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS #15030	730 E GRANT ROAD	TUCSON	AZ	85719	10/12/2012	03/09/2020
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05209	3180 N CAMPBELL AVE	TUCSON	AZ	85719	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03007	9470 E GOLF LINKS RD	TUCSON	AZ	85730	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 10879	7111 E. GOLF LINKS RD.	TUCSON	AZ	85730	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 04103	10405 N. LA CANADA DR.	ORO VALLEY	AZ	85737	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06411	11951 N 1ST AVE	ORO VALLEY	AZ	85737-8787	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03447	12965 N ORACLE RD	TUCSON	AZ	85739	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 04266	2150 W ORANGE GROVE RD	TUCSON	AZ	85741	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07209	3800 W INA RD	TUCSON	AZ	85741	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07304	2175 W INA ROAD	TUCSON	AZ	85741-2648	10/12/2012	11/10/2022
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03630	9220 N. THORNYDALE RD	TUCSON	AZ	85742	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05156	7800 N. CORTARO RD.	TUCSON	AZ	85743	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07232	9250 N COACHLINE BLVD	TUCSON	AZ	85743	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 13822	550 N. SILVERBELL RD	TUCSON	AZ	85745-3107	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06571	2180 W GRANT ROAD	TUCSON	AZ	85745-1142	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03837	1550 W VALENCIA	TUCSON	AZ	85746	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05532	2929 W VALENCIA ROAD	TUCSON	AZ	85746	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07041	9184 E VALENCIA ROAD	TUCSON	AZ	85747-4902	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05750	10315 E BROADWAY BLVD	TUCSON	AZ	85748-3409	10/12/2012	03/09/2020
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07104	1145 S HARRISON ROAD	TUCSON	AZ	85748-6640	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS #15502	8980 E TANQUE VERDE ROAD	TUCSON	AZ	85749	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06645	5525 E RIVER RD	TUCSON	AZ	85750-1949	10/12/2012
CH090160	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 01899	9495 EAST SPEEDWAY BLVD	TUCSON	AZ	85710	07/01/2016	04/21/2025
CH090160	WALGREEN ARIZONA DRUG CO.	WALGREENS SPECIALTY PHARMACY #16500	1830 E. BROADWAY BLVD. SUITE 136	TUCSON	AZ	85719	01/01/2021
CH090160	WALGREEN ARIZONA DRUG CO.	WALGREENS CENTRAL FILL #21372	120 N 83RD AVE STE 200	TOLLESON	AZ	85353	10/01/2021
CH090160	Walgreen Arizona Drug Co.	Walgreens Central Fill #21372	120 N 83rd Ave 200	Tolleson	AZ	85353	07/01/2022	09/30/2022
CH090160	WALGREEN ARIZONA DRUG CO.	DBA WALGREENS SPECIALTY PHARMACY #21393	3627 N CAMPBELL AVE	TUCSON	AZ	85719	01/01/2024
CH09016E	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05532	2929 W VALENCIA ROAD	TUCSON	AZ	85746	01/01/2024
CH09016F	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07463	525 W VALENCIA ROAD	TUCSON	AZ	85706-7636	01/01/2024
CH09016AM	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06953	605 W AJO WAY	TUCSON	AZ	85713-6047	01/01/2024
CH09016AK	WALGREEN ARIZONA DRUG CO.	WALGREENS SPECIALTY PHARMACY #16500	1830 E. BROADWAY BLVD. SUITE 136	TUCSON	AZ	85719	01/01/2024
CH09016B	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06766	1880 E IRVINGTON ROAD	TUCSON	AZ	85714-1754	01/01/2024
CH09016Y	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05209	3180 N CAMPBELL AVE	TUCSON	AZ	85719	01/01/2024
CH09016AD	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05892	3910 E 22ND STREET	TUCSON	AZ	85711	01/01/2024
CH09016P	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 13822	550 N. SILVERBELL RD	TUCSON	AZ	85745-3107	01/01/2024
CH09016T1	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03837	1550 W VALENCIA	TUCSON	AZ	85746	01/01/2024
CH090160	WALGREEN CO	DBA: WALGREENS	17500 PERRIS BLVD	MORENO VALLEY	CA	92551-9547	10/12/2012	08/20/2015
CH090160	WALGREEN CO	DBA: WALGREENS	2370 E MAIN STREET	WOODLAND	CA	95776	10/12/2012	08/20/2015
CH090160	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	10/12/2012	02/14/2020
CH090160	WALGREENS MAIL SERVICE, INC.		8337 S PARK CIRCLE	ORLANDO	FL	32819-9049	07/01/2013	08/20/2015
CH090160	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	01/01/2020	12/01/2021
CH090160	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	01/01/2020
CH090160	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	01/01/2020
CH090160	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	01/01/2020
CH090160	WALMART PHARMACY 10-4490	2565 E COMMERCE CENTER PLACE		TUCSON	AZ	85706	04/01/2020
CH090160	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	07/01/2025
CH090160	WALMART PHARMACY 10-5725	831 E. FORT LOWELL RD.		TUCSON	AZ	85719	04/01/2020
CH090160	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	07/01/2025

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	1/30/2024 5:12:38 PM	2/11/2025 10:02:22 AM	2/11/2025 10:02 AM
Addresses	Billing Address	Insert	Change Request		EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER 450 W Paseo Redondo TUCSON, AZ, AZ 85701	1/28/2025 12:22 PM
Details	Last Recertification Date	Update	Recertification	2/3/2023 5:29:47 PM	1/30/2024 5:12:38 PM	1/30/2024 5:12 PM
Details	Last Recertification Date	Update	Recertification	1/31/2022 1:55:16 PM	2/3/2023 5:29:47 PM	2/3/2023 5:29 PM
Contacts	Primary Contact	Update	Profile Change Request	Wilson, Ocie Pharmacy Director El Rio Santa Cruz Neighborhood Health Center 5202054906	Wilson, Ocie Pharmacy Director El Rio Santa Cruz Neighborhood Health Center 5203093923	11/17/2022 10:37 AM
Contacts	Primary Contact	Update	Group Change Request	Carzoli, Joshua Chief Operating Officer El RIo Health 5203093959	Wilson, Ocie Pharmacy Director El Rio Santa Cruz Neighborhood Health Center 5202054906	11/17/2022 6:51 AM
Contacts	Authorizing Official	Update	Group Change Request	Johnson, Nancy CEO El Rio Health 5203092011	Kuntz, Clinton CEO El RIo Health 5206703909	10/4/2022 6:32 AM
Details	Last Recertification Date	Update	Recertification	2/17/2021 12:51:28 PM	1/31/2022 1:55:16 PM	1/31/2022 1:55 PM
Contacts	Primary Contact	Update	Profile Change Request	Carzoli, Joshua Pharmacy Director El RIo Health 5203093959	Carzoli, Joshua Chief Operating Officer El RIo Health 5203093959	2/24/2021 9:51 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	061333 (AZ)		2/17/2021 12:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/17/2021 12:51 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		947978	2/17/2021 12:51 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AZ	2/17/2021 12:51 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1467439091 ( )		2/17/2021 12:51 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1275519241 ( )		2/17/2021 12:51 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1093791873 ( )		2/17/2021 12:51 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1073599114 ( )		2/17/2021 12:51 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1407083231 ( )		2/17/2021 12:51 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1851615579 ( )		2/17/2021 12:51 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1780993600 ( )		2/17/2021 12:51 PM
Medicaid Billing	NPI: State	Update	Recertification		AZ	2/17/2021 12:51 PM
Details	Last Recertification Date	Update	Recertification	1/28/2020 3:57:07 PM	2/17/2021 12:51:28 PM	2/17/2021 12:51 PM
Details	Last Recertification Date	Update	Recertification	2/21/2019 3:18:17 PM	1/28/2020 3:57:07 PM	1/28/2020 3:57 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1932490109	2/21/2019 3:18 PM
Details	Last Recertification Date	Update	Recertification	2/12/2018 3:42:02 PM	2/21/2019 3:18:17 PM	2/21/2019 3:18 PM
Details	Last Recertification Date	Update	Recertification	2/9/2017 12:00:00 AM	2/12/2018 3:42:02 PM	2/12/2018 3:42 PM
Contacts	Authorizing Official	Update		Johnson, Nancy CEO 5203092011	Johnson, Nancy CEO El Rio Health 5203092011	1/15/2018 9:57 AM
Contacts	Primary Contact	Update		Carzoli, Joshua Pharmacy Director 5203093959	Carzoli, Joshua Pharmacy Director El RIo Health 5203093959	10/13/2017 7:21 PM
Contacts	Primary Contact	Update		Wilson, Ocie Pharmacy Director 5202054906	Carzoli, Joshua Pharmacy Director 5203093959	7/7/2017 10:56 AM
Contacts	Authorizing Official	Insert			Johnson, Nancy CEO 5203092011	7/7/2017 10:56 AM
Addresses	Main Address	Insert			225 WEST IRVINGTON RD TUCSON, AZ 85714	2/9/2017 1:04 PM
Details	Last Recertification Date	Update		3/7/2016 12:00:00 AM	2/9/2017 12:00:00 AM	2/9/2017 1:04 PM
Details	Last Recertification Date	Update		1/28/2015 12:00:00 AM	3/7/2016 12:00:00 AM	3/7/2016 11:47 AM
Contacts	Primary Contact	Insert			Wilson, Ocie Pharmacy Director 5202054906	3/27/2015 6:43 PM
Details	Last Recertification Date	Update		3/7/2014 12:00:00 AM	1/28/2015 12:00:00 AM	1/28/2015 3:00 PM
Details	Last Recertification Date	Update		4/1/2013 12:00:00 AM	3/7/2014 12:00:00 AM	3/7/2014 6:26 PM
Details	Last Recertification Date	Update			4/1/2013 12:00:00 AM	3/15/2013 8:11 AM
Details	Comments Public	Insert			5/4/12 - Added NPI #'s, changed sub-division name and AO and contact phone #.	5/4/2012 10:54 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	5/4/2012 10:44 AM
Medicaid Billing	Medicaid: Number	Insert			061333	5/4/2012 10:44 AM
Medicaid Billing	Medicaid: State	Insert			AZ	5/4/2012 10:44 AM
Medicaid Billing	NPI: Number	Insert			1467439091	5/4/2012 10:44 AM
Medicaid Billing	NPI: Number	Insert			1275519241	5/4/2012 10:44 AM
Medicaid Billing	NPI: Number	Insert			1093791873	5/4/2012 10:44 AM
Medicaid Billing	NPI: Number	Insert			1073599114	5/4/2012 10:44 AM
Medicaid Billing	NPI: Number	Insert			1407083231	5/4/2012 10:44 AM
Medicaid Billing	NPI: Number	Insert			1851615579	5/4/2012 10:44 AM
Medicaid Billing	NPI: Number	Insert			1780993600	5/4/2012 10:44 AM
Details	Last Recertification Date	Insert				6/5/2008 7:16 AM
Details	Grant Number	Insert			H80CS00230	6/5/2008 7:16 AM
Details	340B ID	Insert			CH09016B	6/5/2008 7:16 AM
Details	Is Authorizing Official EHB Data	Insert				6/5/2008 7:16 AM
Dates	Last Date That 340B Drugs Purchased	Insert				6/5/2008 7:16 AM
Details	Medicare Provider Number	Insert				6/5/2008 7:16 AM
Details	Entity Name	Insert			EL RIO SANTA CRUZ NEIGHBORHOOD HEALTH CENTER	6/5/2008 7:16 AM
Details	Program Code	Insert			CH	6/5/2008 7:16 AM
Details	Entity Subname	Insert			EL RIO OB/GYN ASSOCIATES	6/5/2008 7:16 AM
Dates	Participating Approval Date	Insert			6/5/2008 12:00:00 AM	6/5/2008 7:16 AM
Details	State	Insert			Active	6/5/2008 7:16 AM
Dates	Registration Date	Insert			5/18/2008 12:00:00 AM	6/5/2008 7:16 AM
Dates	Signed By Date	Insert			4/18/2008 12:00:00 AM	6/5/2008 7:16 AM
Dates	Start Date	Insert			7/1/2008 12:00:00 AM	6/5/2008 7:16 AM
Terminations	Termination Comments	Insert				6/5/2008 7:16 AM
Terminations	Termination Date	Insert				6/5/2008 7:16 AM
Terminations	Termination Effective Date	Insert				6/5/2008 7:16 AM
Terminations	Termination Reason	Insert				6/5/2008 7:16 AM

340B Drug Pricing Program Database