Covered Entity Details

CH051278G HEARTLAND INTERNATIONAL HEALTH CENTERS (Terminated) - information as of 4/30/2025 10:58:50 PM

Main Details

Name

HEARTLAND INTERNATIONAL HEALTH CENTERS

Subdivision Name

Heartland Health Center - Clark

Type

HRSA-Funded Health Center

Site ID

BPS-H80-008922

340B ID

CH051278G

Grant Number

H80CS00215

Additional Details

Current Program Status

Terminated

Registration Date

12/4/2009

Participating Start Date

1/1/2010

Participating Approval Date

12/21/2009

Last Recertification Date

2/15/2020

Termination Date
Termination Reason

4/1/2020
Other

Contacts

Authorizing Official

Heartland International Health Center
Gwenn Rausch, CEO
(773) 296-7587

Primary Contact

Heartland International Health Center
Randall H Johnson, CFO
(773) 296-7683

Addresses

Street Address

4740 N Clark St
Chicago, IL 60640-4689

Billing Address

HEARTLAND INTERNATIONAL HEALTH CENTER
3048 N WILTON AVE
2ND FLOOR
CHICAGO, IL 60657-6710

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
IL	363843377009
		1407183734

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
CH0512780	Active	BPS-H80-032048	Tapestry 360 Health	Tapestry 360 Health - Administration	1301 W Devon Ave	Chicago	IL
CH051278A	Active	BPS-H80-003767	Tapestry 360 Health	Tapestry 360 Health - SENN HIGH SCHOOL	5900 N GLENWOOD	CHICAGO	IL
CH051278B	Active	BPS-H80-003533	Tapestry 360 Health	Tapestry 360 Health - Touhy	2200 W Touhy	Chicago	IL
CH051278C	Active	BPS-H80-002243	Tapestry 360 Health	Tapestry 360 Health - ROOSEVELT HIGH SCHOOL	3436 W WILSON AVE	CHICAGO	IL
CH051278E	Active	BPS-H80-007595	Tapestry 360 Health	Tapestry 360 Health - LINCOLN SQUARE	2645 W. LAWRENCE	CHICAGO	IL
CH051278F	Active	BPS-H80-003541	Tapestry 360 Health	Tapestry 360 Health - WILSON	845 W WILSON AVE	CHICAGO	IL
CH051278G	Terminated	BPS-H80-008922	HEARTLAND INTERNATIONAL HEALTH CENTERS	Heartland Health Center - Clark	4740 N Clark St	Chicago	IL
CH051278H	Active	BPS-H80-032102	Tapestry 360 Health	Tapestry 360 Health - LAKEVIEW	3154 N Clark St	CHICAGO	IL
CH051278J	Active	BPS-H80-008675	Tapestry 360 Health	Tapestry 360 Health - Hibbard	3244 W Ainslie St	Chicago	IL
CH051278K	Terminated	BPS-H80-010055	Tapestry 360 Health	Heartland Health Center - Uplift Community High School	900 W Wilson Ave	Chicago	IL
CH051278L	Active	BPS-H80-014145	Tapestry 360 Health	Tapestry 360 Health - Devon	1300 W Devon Ave	Chicago	IL
CH051278M	Active	BPS-H80-010516	Tapestry 360 Health	Tapestry 360 Health - Trilogy	1400 W Greenleaf Ave	Chicago	IL
CH051278N	Terminated	BPS-H80-012378	Tapestry 360 Health	Tapestry 360 Health - C4 - Broadway	5710 N Broadway St	Chicago	IL
CH051278P	Terminated	BPS-H80-015138	HEARTLAND INTERNATIONAL HEALTH CENTERS	Heartland Health Center-Niles West	5701 Oakton Street	Skokie	IL
CH051278Q	Active	BPS-H80-015555	Tapestry 360 Health	Tapestry 360 Health - Albany Park	3737 W LAWRENCE AVE	CHICAGO	IL
CH051278R	Terminated	BPS-H80-015139	HEARTLAND INTERNATIONAL HEALTH CENTERS	Heartland Health Center-Niles North	9800 Lawler Ave	Skokie	IL
CH051278S	Active	BPS-H80-018538	Tapestry 360 Health	Tapestry 360 Health -Sullivan	6631 N Bosworth Ave	Chicago	IL
CH051278T	Active	BPS-H80-018675	Tapestry 360 Health	Tapestry 360 Health-Kilmer	6700 N Greenview Avenue	Chicago	IL
CH051278U	Active	BPS-H80-018674	Tapestry 360 Health	Tapestry 360 Health-Thresholds	4423 N Ravenswood Ave	Chicago	IL
CH051278V	Active	BPS-H80-024820	Tapestry 360 Health	Tapestry 360 Health - Skokie	8320 Skokie Blvd	Skokie	IL
CH051278W	Active	BPS-H80-024732	Tapestry 360 Health	Tapestry 360 Health - Gale	1631 W. Jonquil Terrace 1st Floor RM 107	Chicago	IL

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH0512780	ALPHA PHARM LLC	DBA CHICAGO HEALTHMART PHARMACY	1260 W DEVON AVE	CHICAGO	IL	60660	07/01/2019
CH051278L	ALPHA PHARM LLC	DBA CHICAGO HEALTHMART PHARMACY	1260 W DEVON AVE	CHICAGO	IL	60660	10/01/2024
CH0512780	AMERICAN DRUG STORES LLC	DBA OSCO DRUG 230	7530 S STONY ISLAND AVE	CHICAGO	IL	60649	01/01/2023
CH0512780	AMERICAN DRUG STORES LLC	OSCO DRUG #3538	1763 W HOWARD ST	CHICAGO	IL	60626-1626	01/01/2023
CH051278B	AMERICAN DRUG STORES LLC	DBA OSCO DRUG 3407	5532 N CLARK ST	CHICAGO	IL	60640	07/01/2023	04/01/2024
CH0512780	BOND DRUG COMPANY OF ILLINOIS LLC	DBA: WALGREENS #12150	5158 N. LINCOLN AVE	CHICAGO	IL	60625	01/01/2016
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 01308	7410 N CLARK	CHICAGO	IL	60626	01/01/2016
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 02684	4850 OAKTON ST	SKOKIE	IL	60077	01/01/2016
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 02840	1500 W WILSON AVE	CHICAGO	IL	60640	01/01/2016
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04542	5625 N. RIDGE AVE	CHICAGO	IL	60660-3434	01/01/2016
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05057	3153 W IRVING PARK RD	CHICAGO	IL	60618	01/01/2016
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS #13454	6140 N WESTERN AVE	CHICAGO	IL	60659	01/01/2016
CH051278Q	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA WALGREENS SPECIALTY PHARMACY #04505	4025 N. SHERIDAN RD.	CHICAGO	IL	60613	01/01/2018	04/01/2024
CH051278S	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA WALGREENS SPECIALTY PHARMACY #04505	4025 N. SHERIDAN RD.	CHICAGO	IL	60613	01/01/2018	04/01/2024
CH051278N	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA WALGREENS SPECIALTY PHARMACY #04505	4025 N. SHERIDAN RD.	CHICAGO	IL	60613	01/01/2018	04/01/2025
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA WALGREENS SPECIALTY PHARMACY #04505	4025 N. SHERIDAN RD.	CHICAGO	IL	60613	01/01/2018	04/01/2024
CH051278U	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA WALGREENS SPECIALTY PHARMACY #04505	4025 N. SHERIDAN RD.	CHICAGO	IL	60613	01/01/2018	04/01/2024
CH051278K	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA WALGREENS SPECIALTY PHARMACY #04505	4025 N. SHERIDAN RD.	CHICAGO	IL	60613	01/01/2018	04/01/2024
CH051278M	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA WALGREENS SPECIALTY PHARMACY #04505	4025 N. SHERIDAN RD.	CHICAGO	IL	60613	01/01/2018	04/01/2024
CH051278T	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA WALGREENS SPECIALTY PHARMACY #04505	4025 N. SHERIDAN RD.	CHICAGO	IL	60613	01/01/2018	04/01/2024
CH051278J	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA WALGREENS SPECIALTY PHARMACY #04505	4025 N. SHERIDAN RD.	CHICAGO	IL	60613	01/01/2018	04/01/2024
CH051278L	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA WALGREENS SPECIALTY PHARMACY #04505	4025 N. SHERIDAN RD.	CHICAGO	IL	60613	01/01/2018	04/01/2024
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 02619	2100 GREEN BAY ROAD	EVANSTON	IL	60201	04/01/2019
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS #15364	635 CHICAGO AVENUE	EVANSTON	IL	60202	04/01/2019
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04862	4343 N CENTRAL AVE	CHICAGO	IL	60634	04/01/2019
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04936	4040 N. CICERO AVE.	CHICAGO	IL	60641	04/01/2019
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 01593	5230 N MILWAUKEE AVE	CHICAGO	IL	60630	07/01/2019
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03395	3401 W ROOSEVELT RD	CHICAGO	IL	60624	10/01/2019	11/12/2024
CH051278V	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04218	900 DODGE AVENUE	EVANSTON	IL	60202	10/01/2020
CH051278V	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04233	5600 W. FULLERTON	CHICAGO	IL	60639	10/01/2020
CH051278V	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05147	9150 SKOKIE BLVD	SKOKIE	IL	60077	10/01/2020
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 11410	1627 N PULASKI RD	CHICAGO	IL	60639	01/01/2022
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 01417	1931 W CERMAK RD	CHICAGO	IL	60608	01/01/2022
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05121	5935 W ADDISON	CHICAGO	IL	60634	01/01/2022
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05089	7111 S WESTERN AVE	CHICAGO	IL	60636	04/01/2022	02/17/2025
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 02877	2440 W NORTH AVE	CHICAGO	IL	60647	04/01/2022
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04986	4745 W BELMONT AVE	CHICAGO	IL	60641-4410	04/01/2022
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04938	4748 W NORTH AVE	CHICAGO	IL	60639	04/01/2022
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04218	900 DODGE AVENUE	EVANSTON	IL	60202	01/01/2024
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04233	5600 W. FULLERTON	CHICAGO	IL	60639	01/01/2024
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03698	3201 N. BROADWAY ST.	CHICAGO	IL	60657	01/01/2024
CH0512780	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05147	9150 SKOKIE BLVD	SKOKIE	IL	60077	01/01/2024
CH0512780	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/01/2021
CH0512780	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/01/2021
CH0512780	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/01/2021
CH0512780	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/01/2021
CH0512780	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/01/2021
CH0512780	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/01/2021
CH0512780	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/01/2021
CH0512780	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/01/2021
CH0512780	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/01/2021
CH0512780	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/01/2021
CH0512780	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/01/2021
CH0512780	DRUG CENTER PHARMACY INC	DRUG CENTER PHARMACY	845 W WILSON AVE STE 130	CHICAGO	IL	60640	02/12/2024
CH051278F	DRUG CENTER PHARMACY INC	DRUG CENTER PHARMACY	845 W WILSON AVE STE 130	CHICAGO	IL	60640	10/01/2024
CH0512780	GENOA HEALTHCARE LLC	3046 WEST 127TH STREET		BLUE ISLAND	IL	60406	04/01/2023	10/02/2023
CH0512780	GENOA HEALTHCARE LLC	1400 W GREENLEAF AVE STE 101		CHICAGO	IL	60626	04/01/2023
CH0512780	GENOA HEALTHCARE LLC	5710 N. BROADWAY STREET, SUITE P		CHICAGO	IL	60660-4302	04/01/2023
CH0512780	GENOA HEALTHCARE LLC	3348 W 87TH ST STE P		CHICAGO	IL	60652	04/01/2023	10/02/2023
CH0512780	GENOA HEALTHCARE LLC	4423 N RAVENSWOOD AVE STE P100		CHICAGO	IL	60640	04/01/2023
CH051278N	GENOA HEALTHCARE LLC	5710 N. BROADWAY STREET, SUITE P		CHICAGO	IL	60660-4302	10/01/2024	04/01/2025
CH051278M	GENOA HEALTHCARE OF ILLINOIS, LLC	DBA GENOA HEALTHCARE	1400 W GREENLEAF AVENUE, SUITE 101	CHICAGO	IL	60626-2805	10/01/2015
CH051278U	GENOA HEALTHCARE, LLC	4423 N. RAVENSWOOD AVE. STE P100		CHICAGO	IL	60640-5802	10/01/2017
CH0512780	GOLDENSONS MORSE L DRUGS	HERMAN GOLDENSON	MORSE L DRUGS 1407 MORSE AVE	CHICAGO	IL	60626	03/17/2008	01/01/2024
CH051278L	GOLDENSONS MORSE L DRUGS	HERMAN GOLDENSON	MORSE L DRUGS 1407 MORSE AVE	CHICAGO	IL	60626	04/01/2015	01/01/2024
CH051278A	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 01493	5205 N. BROADWAY ST.	CHICAGO	IL	60640	07/01/2021
CH051278A	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 02809	2815 N. WESTERN AVE.	CHICAGO	IL	60618	07/01/2021
CH051278A	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 02862	3944 N. WESTERN AVE.	CHICAGO	IL	60618	07/01/2021
CH051278A	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 02942	401 W. ARMITAGE AVE.	CHICAGO	IL	60614	07/01/2021	02/01/2024
CH051278A	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 04778	101 ASBURY AVE.	EVANSTON	IL	60202	07/01/2021
CH051278A	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 05001	3033 N. BROADWAY ST.	CHICAGO	IL	60657	07/01/2021
CH051278A	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 05681	3311 N. PULASKI RD.	CHICAGO	IL	60641	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 01493	5205 N. BROADWAY ST.	CHICAGO	IL	60640	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 02809	2815 N. WESTERN AVE.	CHICAGO	IL	60618	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 02862	3944 N. WESTERN AVE.	CHICAGO	IL	60618	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 02942	401 W. ARMITAGE AVE.	CHICAGO	IL	60614	07/01/2021	02/01/2024
CH0512780	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 04778	101 ASBURY AVE.	EVANSTON	IL	60202	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 05001	3033 N. BROADWAY ST.	CHICAGO	IL	60657	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 05681	3311 N. PULASKI RD.	CHICAGO	IL	60641	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 05978	3434 DEMPSTER ST.	SKOKIE	IL	60076	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 05987	4800 NORTH DAMEN	CHICAGO	IL	60625	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 06785	3343 W. MONTROSE AVE.	CHICAGO	IL	60618	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08695	3101 N. CLARK	CHICAGO	IL	60657	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08737	2414 N. LINCOLN AVE.	CHICAGO	IL	60614	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08751	4051 N LINCOLN	CHICAGO	IL	60618	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08752	5945 W DEMPSTER ST	MORTON GROVE	IL	60053	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08753	3637 N SOUTHPORT	CHICAGO	IL	60613	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08757	4001 MAIN ST.	SKOKIE	IL	60076	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08980	6510 NORTH SHERIDAN RD.	CHICAGO	IL	60626	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	CVS PHARMACY # 16349	2209 HOWARD ST	EVANSTON	IL	60202	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	CVS PHARMACY # 16361	2656 N ELSTON AVE	CHICAGO	IL	60647	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	CVS PHARMACY # 16771	2939 W ADDISON ST	CHICAGO	IL	60618	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	CVS PHARMACY # 17167	2112 W PETERSON AVE	CHICAGO	IL	60659	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	CVS PHARMACY # 17437	4466 N BROADWAY ST	CHICAGO	IL	60640	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	CVS/PHARMACY # 17683	2650 N CLARK ST	CHICAGO	IL	60614	07/01/2021
CH0512780	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08747	6150 N BROADWAY	CHICAGO	IL	60660	07/01/2021
CH0512780	OMAR PHARMACY INC	DBA DRUG CENTER PHARMACY 101	845 W WILSON AVE	CHICAGO	IL	60640-8090	07/01/2019	08/31/2023
CH0512780	OPTUM PHARMACY 701, LLC	4015 SHOPTON RD STE 600		CHARLOTTE	NC	28217-3025	07/01/2025
CH0512780	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	07/01/2025
CH051278E	PHARMACY ONE PLUS	THURAYA, INC	4753-55 N KEDZIE AVE	CHICAGO	IL	60625	08/22/2011
CH051278J	PHARMACY ONE PLUS	THURAYA, INC	4753-55 N KEDZIE AVE	CHICAGO	IL	60625	04/01/2018
CH051278Q	PHARMACY ONE PLUS	THURAYA, INC	4753-55 N KEDZIE AVE	CHICAGO	IL	60625	10/01/2024
CH051278E	PHARMCHEMETICS INC DBA LAWRENCE HOUSE PH	1001 W LAWRENCE AVE		CHICAGO	IL	60640-5017	07/01/2013
CH0512780	PRIME PLUS LAKEVIEW INC	3156 N CLARK ST		CHICAGO	IL	60657	04/01/2022
CH051278H	PRIME PLUS LAKEVIEW INC	3156 N CLARK ST		CHICAGO	IL	60657	10/01/2024
CH0512780	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/01/2021
CH0512780	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/01/2021
CH0512780	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/01/2021
CH051278A	SHEFFIELD AVENUE CVS, L.L.C.	DBA: CVS/PHARMACY # 03690	1714 N. SHEFFIELD AVE.	CHICAGO	IL	60614	07/01/2021
CH0512780	SHEFFIELD AVENUE CVS, L.L.C.	DBA: CVS/PHARMACY # 03690	1714 N. SHEFFIELD AVE.	CHICAGO	IL	60614	07/01/2021
CH0512780	SUPER CARE PHARMACY, INC	8305 SKOKIE BLVD		SKOKIE	IL	60077-2546	01/01/2019
CH051278V	SUPER CARE PHARMACY, INC	8305 SKOKIE BLVD		SKOKIE	IL	60077-2546	10/01/2024
CH0512780	WALGREEN CO	DBA: WALGREENS #15525	201 E. HURON STREET, SUITE 01-210	CHICAGO	IL	60611	01/01/2019
CH0512780	Walgreen CO	DBA Walgreens Central Fill #21417	599 S Schmidt Rd Ste A	Bolingbrook	IL	60440-9405	10/01/2023
CH051278L	Walgreen CO	DBA Walgreens Central Fill #21417	599 S Schmidt Rd Ste A	Bolingbrook	IL	60440-9405	10/01/2024
CH0512780	WALGREEN CO.	DBA: WALGREENS # 00194	4801 N LINCOLN AVE	CHICAGO	IL	60625	01/01/2016	04/01/2024
CH0512780	WALGREEN CO.	DBA: WALGREENS # 00252	7510 N WESTERN AVE	CHICAGO	IL	60645	01/01/2016
CH0512780	WALGREEN CO.	DBA: WALGREENS # 03950	4343 N KEDZIE AVE	CHICAGO	IL	60618	01/01/2016
CH0512780	WALGREEN CO.	DBA: WALGREENS # 06727	4720 N MARINE DRIVE	CHICAGO	IL	60640-5120	01/01/2016
CH0512780	WALGREEN CO.	DBA: WALGREENS # 06980	3019 W PETERSON AVE	CHICAGO	IL	60659-3417	01/01/2016
CH0512780	WALGREEN CO.	DBA: WALGREENS # 09709	4010 W LAWRENCE AVE	CHICAGO	IL	60630	01/01/2016
CH0512780	WALGREEN CO.	DBA: WALGREENS #13798	5440 N. CLARK ST.	CHICAGO	IL	60640	01/01/2016
CH0512780	WALGREEN CO.	DBA: WALGREENS #15197	6121 N BROADWAY ST.	CHICAGO	IL	60660	01/01/2016
CH0512780	WALGREEN CO.	DBA: WALGREENS #15004	953 W. IRVING PARK RD.	CHICAGO	IL	60613	04/01/2017
CH0512780	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY#16501	6500 N CLARK ST SUITE 101	CHICAGO	IL	60626	04/01/2017
CH051278M	WALGREEN CO.	DBA: WALGREENS #15493	1333 W. BELMONT AVENUE	CHICAGO	IL	60657	01/01/2018	04/01/2024
CH051278T	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #16498	2351 E 71ST ST SUITE A	CHICAGO	IL	60649	01/01/2018	04/01/2024
CH0512780	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #13832	4339 DIPAOLO CENTER	GLENVIEW	IL	60025	01/01/2018
CH051278U	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #13832	4339 DIPAOLO CENTER	GLENVIEW	IL	60025	01/01/2018	04/01/2024
CH051278T	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #13832	4339 DIPAOLO CENTER	GLENVIEW	IL	60025	01/01/2018	04/01/2024
CH051278M	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #13832	4339 DIPAOLO CENTER	GLENVIEW	IL	60025	01/01/2018	04/01/2024
CH051278Q	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #13832	4339 DIPAOLO CENTER	GLENVIEW	IL	60025	01/01/2018	04/01/2024
CH051278Q	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #16498	2351 E 71ST ST SUITE A	CHICAGO	IL	60649	01/01/2018	04/01/2024
CH051278L	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #13832	4339 DIPAOLO CENTER	GLENVIEW	IL	60025	01/01/2018	04/01/2024
CH051278N	WALGREEN CO.	DBA: WALGREENS #15493	1333 W. BELMONT AVENUE	CHICAGO	IL	60657	01/01/2018	04/01/2025
CH051278U	WALGREEN CO.	DBA: WALGREENS #15493	1333 W. BELMONT AVENUE	CHICAGO	IL	60657	01/01/2018	04/01/2024
CH051278S	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #16498	2351 E 71ST ST SUITE A	CHICAGO	IL	60649	01/01/2018	04/01/2024
CH051278Q	WALGREEN CO.	DBA: WALGREENS #15493	1333 W. BELMONT AVENUE	CHICAGO	IL	60657	01/01/2018	04/01/2024
CH051278L	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #13832	4339 DIPAOLO CENTER	GLENVIEW	IL	60025	01/01/2018	04/01/2024
CH051278U	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #16498	2351 E 71ST ST SUITE A	CHICAGO	IL	60649	01/01/2018	04/01/2024
CH051278T	WALGREEN CO.	DBA: WALGREENS #15493	1333 W. BELMONT AVENUE	CHICAGO	IL	60657	01/01/2018	04/01/2024
CH051278U	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #16498	2351 E 71ST ST SUITE A	CHICAGO	IL	60649	01/01/2018	04/01/2024
CH051278S	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #13832	4339 DIPAOLO CENTER	GLENVIEW	IL	60025	01/01/2018	04/01/2024
CH0512780	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #16498	2351 E 71ST ST SUITE A	CHICAGO	IL	60649	01/01/2018
CH051278L	WALGREEN CO.	DBA: WALGREENS #15493	1333 W. BELMONT AVENUE	CHICAGO	IL	60657	01/01/2018	04/01/2024
CH051278K	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #16498	2351 E 71ST ST SUITE A	CHICAGO	IL	60649	01/01/2018	04/01/2024
CH051278T	WALGREEN CO.	DBA: WALGREENS #15493	1333 W. BELMONT AVENUE	CHICAGO	IL	60657	01/01/2018	04/01/2024
CH051278J	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #16498	2351 E 71ST ST SUITE A	CHICAGO	IL	60649	01/01/2018	04/01/2024
CH0512780	WALGREEN CO.	DBA: WALGREENS #15493	1333 W. BELMONT AVENUE	CHICAGO	IL	60657	01/01/2018	04/01/2024
CH051278N	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #13832	4339 DIPAOLO CENTER	GLENVIEW	IL	60025	01/01/2018	04/01/2025
CH051278J	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #13832	4339 DIPAOLO CENTER	GLENVIEW	IL	60025	01/01/2018	04/01/2024
CH051278N	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #16498	2351 E 71ST ST SUITE A	CHICAGO	IL	60649	01/01/2018	04/01/2025
CH051278M	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #16498	2351 E 71ST ST SUITE A	CHICAGO	IL	60649	01/01/2018	04/01/2024
CH051278K	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #13832	4339 DIPAOLO CENTER	GLENVIEW	IL	60025	01/01/2018	04/01/2024
CH051278J	WALGREEN CO.	DBA: WALGREENS #15493	1333 W. BELMONT AVENUE	CHICAGO	IL	60657	01/01/2018	04/01/2024
CH051278K	WALGREEN CO.	DBA: WALGREENS #15493	1333 W. BELMONT AVENUE	CHICAGO	IL	60657	01/01/2018	04/01/2024
CH051278S	WALGREEN CO.	DBA: WALGREENS #15493	1333 W. BELMONT AVENUE	CHICAGO	IL	60657	01/01/2018	04/01/2024
CH051278S	WALGREEN CO.	DBA: WALGREENS #15493	1333 W. BELMONT AVENUE	CHICAGO	IL	60657	01/01/2018	04/01/2024
CH051278L	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #16498	2351 E 71ST ST SUITE A	CHICAGO	IL	60649	01/01/2018	04/01/2024
CH051278J	WALGREEN CO.	DBA: WALGREENS # 07359	3222 N. MILWAUKEE AVENUE	CHICAGO	IL	60618-5106	04/01/2018
CH051278J	WALGREEN CO.	DBA: WALGREENS # 10649	3424 W BELMONT AVE	CHICAGO	IL	60618	04/01/2018
CH051278J	WALGREEN CO.	DBA: WALGREENS # 07359	3222 N. MILWAUKEE AVENUE	CHICAGO	IL	60618-5106	04/01/2018
CH0512780	WALGREEN CO.	DBA: WALGREENS #21447	3513 N HALSTED ST	CHICAGO	IL	60657	01/01/2019
CH0512780	WALGREEN CO.	DBA: WALGREENS #15066	3945 DEMPSTER ST	SKOKIE	IL	60076	01/01/2019
CH0512780	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #15305	912 W BELMONT AVE	CHICAGO	IL	60657	04/01/2019
CH0512780	WALGREEN CO.	DBA: WALGREENS #13975	711 W NORTH AVE STE #204	CHICAGO	IL	60610	04/01/2019	09/18/2023
CH0512780	WALGREEN CO.	DBA: WALGREENS # 09038	4001 W IRVING PARK RD	CHICAGO	IL	60641-2926	04/01/2019
CH0512780	WALGREEN CO.	DBA: WALGREENS 16299	331 W. SURF ST. SUITE 101	CHICAGO	IL	60657-7160	04/01/2019	09/28/2020
CH0512780	WALGREEN CO.	DBA: WALGREENS # 01096	3646 N BROADWAY	CHICAGO	IL	60613	04/01/2019
CH0512780	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #09399	2835 N SHEFFIELD AVE STE 505	CHICAGO	IL	60657	07/01/2019
CH0512780	WALGREEN CO.	DBA: WALGREENS # 07359	3222 N. MILWAUKEE AVENUE	CHICAGO	IL	60618-5106	07/01/2019
CH0512780	WALGREEN CO.	DBA: WALGREENS # 10649	3424 W BELMONT AVE	CHICAGO	IL	60618	07/01/2019
CH051278V	WALGREEN CO.	DBA: WALGREENS # 06866	1378 MINER STREET	DES PLAINES	IL	60016-4389	10/01/2020
CH0512780	WALGREEN CO.	DBA: WALGREENS #15507	3800 W MADISON STREET SUITE 101	CHICAGO	IL	60624	07/01/2021
CH0512780	WALGREEN CO.	DBA WALGREENS #15971	259 E. ERIE STREET SUITE 250	CHICAGO	IL	60611	07/01/2021
CH0512780	WALGREEN CO.	DBA: WALGREENS # 03949	3046 N HALSTED ST	CHICAGO	IL	60657	01/01/2022
CH0512780	WALGREEN CO.	DBA: WALGREENS # 01375	1200 N DEARBORN ST	CHICAGO	IL	60610-8341	01/01/2022
CH0512780	WALGREEN CO.	DBA: WALGREENS # 00178	740 W DIVERSEY PKWY	CHICAGO	IL	60614	01/01/2022
CH0512780	WALGREEN CO.	DBA: WALGREENS # 00259	3358 N WESTERN	CHICAGO	IL	60618	04/01/2022
CH051278A	WALGREEN CO.	DBA: WALGREENS # 00249	1601 N WELLS	CHICAGO	IL	60614	04/01/2022
CH051278A	WALGREEN CO.	DBA: WALGREENS # 01173	1520 W FULLERTON	CHICAGO	IL	60614	04/01/2022
CH0512780	WALGREEN CO.	DBA: WALGREENS # 03948	5140 W DIVERSEY AVE	CHICAGO	IL	60639	04/01/2022
CH0512780	WALGREEN CO.	DBA: WALGREENS # 01173	1520 W FULLERTON	CHICAGO	IL	60614	01/01/2024
CH0512780	WALGREEN CO.	DBA: WALGREENS # 09470	4817 W FULLERTON AVE	CHICAGO	IL	60639-2503	01/01/2024
CH0512780	WALGREEN CO.	DBA: WALGREENS # 06866	1378 MINER STREET	DES PLAINES	IL	60016-4389	01/01/2024
CH0512780	WALGREEN CO.	DBA: WALGREENS # 00249	1601 N WELLS	CHICAGO	IL	60614	01/01/2024
CH051278B	WALGREEN CO.	DBA: WALGREENS # 00252	7510 N WESTERN AVE	CHICAGO	IL	60645	10/01/2024
CH051278Q	WALGREEN CO.	DBA: WALGREENS # 09709	4010 W LAWRENCE AVE	CHICAGO	IL	60630	10/01/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2020 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		9/30/2017 12:00:00 AM	2/24/2020 7:29 AM
Details	State	Update	Termination Request	Active	To Be Terminated	2/24/2020 7:29 AM
Terminations	Termination Comments	Update	Termination Request		This Site was moved out of our scope effective 2 28 2018 and patients were followed at Heartland International Health Center sites nearby. There was little or no 340 B activity there and to the best of my knowledge no 340B drugs were purchased there through our program after September of 2017.	2/24/2020 7:29 AM
Terminations	Termination Date	Update	Termination Request		4/1/2020 12:00:00 AM	2/24/2020 7:29 AM
Terminations	Termination Effective Date	Update	Termination Request		2/28/2018 12:00:00 AM	2/24/2020 7:29 AM
Terminations	Termination Reason	Update	Termination Request		Other	2/24/2020 7:29 AM
Details	Last Recertification Date	Update	Recertification	2/6/2019 4:09:58 PM	2/15/2020 1:25:14 PM	2/15/2020 1:25 PM
Contacts	Primary Contact	Update	Change Request	COLLIER, HUELL BILLING MANAGER Heartland International Health Center 7732967544	Johnson, Randall H CFO Heartland International Health Center 7732967683	1/21/2020 10:00 AM
Details	Last Recertification Date	Update	Recertification	2/12/2018 5:00:37 PM	2/6/2019 4:09:58 PM	2/6/2019 4:09 PM
Details	Last Recertification Date	Update	Recertification	1/26/2017 12:00:00 AM	2/12/2018 5:00:37 PM	2/12/2018 5:00 PM
Contacts	Primary Contact	Update	Recertification	COLLIER, HUELL BILLING MANAGER 7732967544	COLLIER, HUELL BILLING MANAGER Heartland International Health Center 7732967544	2/12/2018 4:57 PM
Contacts	Authorizing Official	Update	AO Change Request	RAUSCH, GWEEN CEO 7732967587	Rausch, Gwenn CEO Heartland International Health Center 7732967587	2/12/2018 9:04 AM
Addresses	Main Address	Insert			4740 N Clark St Chicago, IL 60640-4689	1/26/2017 2:34 PM
Contacts	Authorizing Official	Update		CHOUCAIR, BECHARA EXECUTIVE AND MEDICAL DIRECTOR 7737511700	RAUSCH, GWEEN CEO 7732967587	1/26/2017 2:34 PM
Contacts	Primary Contact	Update		BELTRAN, TONY ACTING EXECUTIVE DIRECTOR & COO 7737511757	COLLIER, HUELL BILLING MANAGER 7732967544	1/26/2017 2:34 PM
Details	Last Recertification Date	Update		2/16/2016 12:00:00 AM	1/26/2017 12:00:00 AM	1/26/2017 2:34 PM
Details	Last Recertification Date	Update		1/28/2015 12:00:00 AM	2/16/2016 12:00:00 AM	2/16/2016 12:18 PM
Details	Last Recertification Date	Update		3/23/2014 12:00:00 AM	1/28/2015 12:00:00 AM	1/28/2015 2:07 PM
Details	Last Recertification Date	Update		4/1/2013 12:00:00 AM	3/23/2014 12:00:00 AM	3/23/2014 11:46 PM
Details	Entity Name	Update		HEARTLAND INTERNATIONAL HEALTH CENTER	HEARTLAND INTERNATIONAL HEALTH CENTERS	3/23/2014 11:46 PM
Details	Entity Subname	Update		HEARTLAND HEALTH CENTER - CLARK	Heartland Health Center - Clark	3/23/2014 11:46 PM
Addresses	Billing Address	Insert			HEARTLAND INTERNATIONAL HEALTH CENTER 3048 N WILTON AVE 2ND FLOOR CHICAGO, IL 60657-6710	7/3/2013 12:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/3/2013 12:54 PM
Medicaid Billing	Medicaid: Number	Insert			363843377009	7/3/2013 12:54 PM
Medicaid Billing	Medicaid: State	Insert			IL	7/3/2013 12:54 PM
Medicaid Billing	NPI: Number	Insert			1407183734	7/3/2013 12:54 PM
Details	Last Recertification Date	Update			4/1/2013 12:00:00 AM	2/13/2013 2:12 PM
Contacts	Primary Contact	Insert			BELTRAN, TONY ACTING EXECUTIVE DIRECTOR & COO 7737511757	3/26/2010 12:40 PM
Contacts	Authorizing Official	Insert			CHOUCAIR, BECHARA EXECUTIVE AND MEDICAL DIRECTOR 7737511700	12/21/2009 5:29 PM
Details	Last Recertification Date	Insert				12/21/2009 5:29 PM
Details	Grant Number	Insert			H80CS00215	12/21/2009 5:29 PM
Details	340B ID	Insert			CH051278G	12/21/2009 5:29 PM
Details	Is Authorizing Official EHB Data	Insert				12/21/2009 5:29 PM
Dates	Last Date That 340B Drugs Purchased	Insert				12/21/2009 5:29 PM
Details	Medicare Provider Number	Insert				12/21/2009 5:29 PM
Details	Entity Name	Insert			HEARTLAND INTERNATIONAL HEALTH CENTER	12/21/2009 5:29 PM
Details	Program Code	Insert			CH	12/21/2009 5:29 PM
Details	Entity Subname	Insert			HEARTLAND HEALTH CENTER - CLARK	12/21/2009 5:29 PM
Dates	Participating Approval Date	Insert			12/21/2009 12:00:00 AM	12/21/2009 5:29 PM
Details	State	Insert			Active	12/21/2009 5:29 PM
Dates	Registration Date	Insert			12/4/2009 12:00:00 AM	12/21/2009 5:29 PM
Dates	Signed By Date	Insert			11/20/2009 12:00:00 AM	12/21/2009 5:29 PM
Dates	Start Date	Insert			1/1/2010 12:00:00 AM	12/21/2009 5:29 PM
Terminations	Termination Comments	Insert				12/21/2009 5:29 PM
Terminations	Termination Date	Insert				12/21/2009 5:29 PM
Terminations	Termination Effective Date	Insert				12/21/2009 5:29 PM
Terminations	Termination Reason	Insert				12/21/2009 5:29 PM

340B Drug Pricing Program Database