Covered Entity Details

CH10131E CLACKAMAS, COUNTY OF (Active) - information as of 6/21/2025 12:04:31 AM

Main Details

Name

CLACKAMAS, COUNTY OF

Subdivision Name

Lake Road Health Center

Type

HRSA-Funded Health Center

Site ID

BPS-H80-038255

340B ID

CH10131E

Grant Number

H80CS00547

Additional Details

Current Program Status

Active

Registration Date

11/19/2010

Participating Start Date

1/1/2011

Participating Approval Date

11/22/2010

Last Recertification Date

2/12/2025

Contacts

Authorizing Official

Clackamas County
Sarah Ann Jacobson, Health Center Administration & Financial Services Manager
(503) 201-1890

Primary Contact

Clackamas County Health Centers
Adam Kearl, Admin Services Manager
(971) 276-5002

Addresses

Street Address

6605 SE Lake Road
Milwaukie, OR 97222-2161

Billing Address

CLACKAMAS COUNTY HEALTH CENTERS
2051 KAEN ROAD. #367
ATTENTION: ACCOUNTS PAYABLE
OREGON CITY, OR 97045-4035

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
OR	022710	1447507215,1720017809

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	Address Cont.	City	State
CH101310	Active	BPS-H80-005297	CLACKAMAS, COUNTY OF	Clackamas Health Centers Administration	2051 Kaen Road STE 367		Oregon City	OR
CH10131A	Active	BPS-H80-013476	CLACKAMAS, COUNTY OF	Beavercreek Health Clinic	110 Beavercreek Road Suite 100		Oregon City	OR
CH10131B	Active	BPS-H80-034331	CLACKAMAS, COUNTY OF	Sandy Health Center	39740 Pleasant St		Sandy	OR
CH10131D	Terminated	BPS-H80-036233	CLACKAMAS, COUNTY OF	Treatment Court Services	1011 Courthouse Rd.		Oregon City	OR
CH10131E	Active	BPS-H80-038255	CLACKAMAS, COUNTY OF	Lake Road Health Center	6605 SE Lake Road		Milwaukie	OR
CH10131F	Active	BPS-H80-013473	CLACKAMAS, COUNTY OF	Sunnyside Health Clinic	9775 SE Sunnyside Rd STE 200		Happy Valley	OR
CH10131H	Active	BPS-H80-002638	CLACKAMAS, COUNTY OF	Oregon City School Based Health Center	19761 Beavercreek Rd	Rm A-145	Oregon City	OR
CH10131J	Terminated	BPS-H80-012441	CLACKAMAS, COUNTY OF	Sandy School Based Health Center & Sandy Health Clinic	37400 Bell Street	Rm 4-18D	Sandy	OR
CH10131K	Terminated	BPS-H80-013471	CLACKAMAS, COUNTY OF	Canby School Based Health Center	721 SW 4th Avenue		Canby	OR
CH10131M	Active	BPS-H80-008737	CLACKAMAS, COUNTY OF	Gladstone Health Clinic	18911 Portland Ave		Gladstone	OR
CH10131N	Active	BPS-H80-024552	CLACKAMAS, COUNTY OF	Rex Putnam High School SBHC	4950 SE Roethe Rd	Rm D50-D73	Milwaukie	OR
CH10131P	Active	BPS-H80-033985	CLACKAMAS, COUNTY OF	Adrienne C. Nelson High School SBHC	14897 SE Parklane Dr Rm E102A		Happy Valley	OR
CH10131Q	Active	BPS-H80-033986	CLACKAMAS, COUNTY OF	Clackamas High School SBHC	14486 SE 122nd Ave Rm B101A		Clackamas	OR
CH10131R	Terminated	BPS-H80-036234	COUNTY OF CLACKAMAS	DSB 3rd Floor Behavioral Health	150 Beavercreek Road STE 305		Oregon City	OR

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH101310	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	04/01/2018
CH101310	FRED MEYER	CLACKAMAS STORE	16301 S E 82ND DRIVE	CLACKAMAS	OR	97015	04/01/2013
CH101310	FRED MEYER 663	16625 362ND AVENUE		SANDY	OR	97055	10/01/2014
CH101310	FRED MEYER INC	8955 S.E. 82ND AVENUE		HAPPY VALLEY	OR	97086	01/01/2014
CH101310	FRED MEYER STORES INC	FRED MEYER PHARMACY #240	14700 SE MCLOUGHLIN BLVD	MILWAUKIE	OR	97267-1417	04/01/2013	11/04/2024
CH101310	FRED MEYER STORES INC	FRED MEYER PHARMACY #242	1839 MOLALLA AVENUE	OREGON CITY	OR	97045	04/01/2013
CH101310	FRED MEYER STORES INC	FRED MEYER PHARMACY #651	1401 SE FIRST AVE	CANBY	OR	97013	01/01/2014	11/04/2024
CH101310	GENEVA WOODS PHARMACY	6600 NE 112TH CT	STE 103	VANCOUVER	WA	98662-5494	04/01/2018	05/05/2019
CH101310	GENEVA WOODS PHARMACY	16250 SE MCLOUGHLIN BLVD		MILWAUKIE	OR	97267-4657	04/01/2018	05/05/2019
CH101310	GENOA A QOL HEALTHCARE COMPANY LLC		998 LIBRARY COURT, ROOM 4	OREGON CITY	OR	97045	01/01/2014	05/23/2023
CH101310	GENOA HEALTHCARE LLC	110 BEAVERCREEK RD, STE 102		OREGON CITY	OR	97045	07/01/2016
CH101310	GENOA HEALTHCARE LLC	39740 PLEASANT ST		SANDY	OR	97055	01/01/2023	04/25/2025
CH101310	GENOA HEALTHCARE LLC	150 BEAVERCREEK RD STE 304		OREGON CITY	OR	97045	05/24/2023
CH101310	HEALTHY OPTIONS INC	DBA POSTAL PRESCRIPTION SVCS	3500 SE 26TH AVE PO BOX 2718	PORTLAND	OR	97202	07/01/2018
CH101310	OREGON CVS PHARMACY, L.L.C.	CVS PHARMACY # 16127	9000 SE SUNNYSIDE RD	CLACKAMAS	OR	97015	01/01/2021
CH101310	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	04/01/2018	02/22/2023
CH10131A	SAFEWAY INC	SAFEWAY PHARMACY #2993	13434 COLTON PLACE	OREGON CITY	OR	97045	08/30/2010
CH101310	SAFEWAY INC	SAFEWAY PHARMACY #2993	13434 COLTON PLACE	OREGON CITY	OR	97045	11/10/2011
CH101310	SAFEWAY INC	SAFEWAY PHARMACY #4387	95 82ND DRIVE	GLADSTONE	OR	97027	01/01/2014
CH101310	SAFEWAY INC	SAFEWAY PHARMACY #1751	1525 W MAIN ST	MOLALLA	OR	97038	01/01/2014
CH101310	SAFEWAY INC	SAFEWAY PHARMACY #0782	37601 HWY 26	SANDY	OR	97055	10/01/2014
CH101310	THRIFTY PAYLESS, INC.	RITE AID #5352	10860 S.E. OAK STREET	MILWAUKIE	OR	97222	01/01/2014	08/01/2023
CH101310	THRIFTY PAYLESS, INC.	RITE AID #5332	1900 MCLOUGHLIN BLVD.	OREGON CITY	OR	97045	01/01/2014
CH101310	THRIFTY PAYLESS, INC.	RITE AID #5325	891 S.E. 1ST AVENUE	CANBY	OR	97013	01/01/2014	08/01/2023
CH101310	THRIFTY PAYLESS, INC.	RITE AID #5326	12002 SE SUNNYSIDE ROAD	CLACKAMAS	OR	97015	01/01/2014
CH101310	THRIFTY PAYLESS, INC.	RITE AID #5331	16390 BOONES FERRY ROAD	LAKE OSWEGO	OR	97035	04/01/2020	08/01/2023
CH101310	THRIFTY PAYLESS, INC.	RITE AID #5327	1555 N.E. DIVISION STREET	GRESHAM	OR	97030	04/01/2020	01/01/2024
CH101310	THRIFTY PAYLESS, INC.	RITE AID #5359	11930 SE DIVISION STREET	PORTLAND	OR	97266	04/01/2020	08/01/2023
CH101310	THRIFTY PAYLESS, INC.	RITE AID #5358	16401 SE DIVISION STREET	PORTLAND	OR	97236	04/01/2020	09/19/2023
CH101310	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/01/2018
CH101310	WAL-MART PHARMACY 10-3144	15600 SE MCLOUGHLIN BLVD		MILWAUKIE	OR	97267	07/01/2018
CH101310	WAL-MART PHARMACY 10-5440	10000 SOUTHEAST 82ND AVENUE		HAPPY VALLEY	OR	97086	07/01/2018
CH101310	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/01/2018
CH101310	WALGREEN CO.	DBA: WALGREENS # 01100	9159 SE 82ND AVE	HAPPY VALLEY	OR	97086	04/01/2018
CH101310	WALGREEN CO.	DBA: WALGREENS # 03838	1950 NE BURNSIDE RD	GRESHAM	OR	97030	04/01/2018
CH101310	WALGREEN CO.	DBA: WALGREENS # 15927	11995 SE SUNNYSIDE RD	HAPPY VALLEY	OR	97015	04/01/2018
CH101310	WALGREEN CO.	DBA:WALGREENS #15548	14617 SE MCLOUGHLIN BLVD.	MILWAUKIE	OR	97267	04/01/2018	06/08/2020
CH101310	WALGREEN CO.	DBA: WALGREENS # 03801	1310 MOLALLA AVE	OREGON CITY	OR	97045	04/01/2018
CH101310	WALGREEN CO.	DBA: WALGREENS #10137	38241 PROCTOR BLVD.	SANDY	OR	97055-8019	04/01/2018
CH101310	WALGREEN CO.	DBA: WALGREENS #13727	20100 MCLOUGHLIN BLVD.	GLADSTONE	OR	97027	04/01/2018
CH101310	WALGREEN CO.	DBA: WALGREENS # 09544	10903 SE OAK ST	MILWAUKIE	OR	97222-6641	10/01/2020
CH101310	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	07/01/2020
CH101310	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/01/2018
CH101310	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	04/01/2018	12/01/2022
CH101310	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/01/2018
CH101310	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/01/2018
CH101310	WALGREENS.COM, INC.	DBA: WALGREENS	2225 S. PRICE ROAD	CHANDLER	AZ	85286	07/01/2020
CH101310	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	01/01/2024
CH101310	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	2/6/2024 12:17:11 PM	2/12/2025 12:56:10 PM	2/12/2025 12:56 PM
Addresses	Main Address	Update	Change Request	150 Beavercreek Road West Wing Oregon City, OR 97045	6605 SE Lake Road Milwaukie, OR 97222-2161	3/25/2024 11:27 AM
Details	Entity Subname	Update	Change Request	DSB 4th Floor Behavioral Health	Lake Road Health Center	3/25/2024 11:27 AM
Details	Last Recertification Date	Update	Recertification	2/2/2023 8:25:39 AM	2/6/2024 12:17:11 PM	2/6/2024 12:17 PM
Addresses	Main Address	Update	Recertification	1002 Library Ct Oregon City, OR 97045-4066	150 Beavercreek Road West Wing Oregon City, OR 97045	2/2/2023 8:25 AM
Details	Last Recertification Date	Update	Recertification	1/31/2022 6:33:26 PM	2/2/2023 8:25:39 AM	2/2/2023 8:25 AM
Details	Entity Subname	Update	Recertification	Stewart Behavioral Health Clinic	DSB 4th Floor Behavioral Health	2/2/2023 8:25 AM
Contacts	Authorizing Official	Update	Group Change Request	Cockrell, Deborah FQHC Director Clackamas County Health Centers 5037425495	Jacobson, Sarah Ann Health Center Administration & Financial Services Manager Clackamas County 5032011890	6/1/2022 1:04 PM
Contacts	Primary Contact	Update	Group Change Request	Jacobson, Sarah Ann Health Center Administration & Financial Services Manager Clackamas County 5032011890	Kearl, Adam Admin Services Manager Clackamas County Health Centers 9712765002	6/1/2022 1:04 PM
Details	Last Recertification Date	Update	Recertification	2/1/2021 4:32:03 PM	1/31/2022 6:33:26 PM	1/31/2022 6:33 PM
Contacts	Primary Contact	Update	Change Request	Johnson, Ed Admin & Finance Manager Clackamas County Health Centers 5037425325	Jacobson, Sarah Ann Health Center Administration & Financial Services Manager Clackamas County 5032011890	2/24/2021 12:33 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1447507215	2/1/2021 4:32 PM
Medicaid Billing	NPI: State	Insert	Recertification		OR	2/1/2021 4:32 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1720017809	2/1/2021 4:32 PM
Medicaid Billing	NPI: State	Insert	Recertification		OR	2/1/2021 4:32 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1720017809 ( )		2/1/2021 4:32 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1447507215 ( )		2/1/2021 4:32 PM
Details	Last Recertification Date	Update	Recertification	2/5/2020 5:35:40 PM	2/1/2021 4:32:03 PM	2/1/2021 4:32 PM
Details	Last Recertification Date	Update	Recertification	2/7/2019 12:45:21 PM	2/5/2020 5:35:40 PM	2/5/2020 5:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/18/2019 12:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		022710	2/18/2019 12:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	2/18/2019 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720017809	2/18/2019 12:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447507215	2/18/2019 12:25 PM
Details	Last Recertification Date	Update	Recertification	2/8/2018 10:47:15 AM	2/7/2019 12:45:21 PM	2/7/2019 12:45 PM
Details	Last Recertification Date	Update	Recertification	2/14/2017 12:00:00 AM	2/8/2018 10:47:15 AM	2/8/2018 10:47 AM
Contacts	Primary Contact	Update		Johnson, Ed Admin & Finance Manager 5037425325	Johnson, Ed Admin & Finance Manager Clackamas County Health Centers 5037425325	1/10/2018 11:57 AM
Contacts	Authorizing Official	Update		Cockrell, Deborah FQHC Director 5037425495	Cockrell, Deborah FQHC Director Clackamas County Health Centers 5037425495	1/10/2018 11:56 AM
Contacts	Primary Contact	Update		Smith, Daniel Health Centers Admin & Financial Services Manager 5037425325	Johnson, Ed Admin & Finance Manager 5037425325	7/25/2017 8:27 AM
Contacts	Authorizing Official	Update		Swift, Richard Interim FQHC DIRECTOR 5036505694	Cockrell, Deborah FQHC Director 5037425495	7/25/2017 8:27 AM
Addresses	Main Address	Insert			1002 Library Ct Oregon City, OR 97045-4066	2/14/2017 12:12 PM
Details	Last Recertification Date	Update		2/24/2016 12:00:00 AM	2/14/2017 12:00:00 AM	2/14/2017 12:12 PM
Details	Last Recertification Date	Update		3/4/2015 12:00:00 AM	2/24/2016 12:00:00 AM	2/24/2016 2:27 PM
Contacts	Primary Contact	Update		Burdine, Angela Interim Health Centers Admin and Financial Services Manager 5037425319	Smith, Daniel Health Centers Admin & Financial Services Manager 5037425325	9/4/2015 7:34 AM
Details	Last Recertification Date	Update		3/15/2014 12:00:00 AM	3/4/2015 12:00:00 AM	3/4/2015 1:26 PM
Addresses	Billing Address	Insert			CLACKAMAS COUNTY HEALTH CENTERS 2051 KAEN ROAD. #367 ATTENTION: ACCOUNTS PAYABLE OREGON CITY, OR 97045-4035	1/27/2015 4:48 PM
Contacts	Primary Contact	Update		Scott, Mary Interim Health Centers Admin and Financial Services Manager 5037425325	Burdine, Angela Interim Health Centers Admin and Financial Services Manager 5037425319	9/30/2014 11:05 PM
Contacts	Authorizing Official	Update		EDWARDS, DAVID FQHC DIRECTOR 5037425325	Swift, Richard Interim FQHC DIRECTOR 5036505694	9/16/2014 6:08 PM
Details	Entity Subname	Update		STEWART COMMUNITY CENTER	Stewart Behavioral Health Clinic	9/16/2014 6:08 PM
Contacts	Primary Contact	Update		EDWARDS, DAVID FQHC DIRECTOR 5037425325	Scott, Mary Interim Health Centers Admin and Financial Services Manager 5037425325	9/3/2014 6:20 PM
Details	Last Recertification Date	Update		4/1/2013 12:00:00 AM	3/15/2014 12:00:00 AM	3/15/2014 7:21 AM
Details	Entity Name	Update		CLACKAMAS COUNTY COMMUNITY HEALTH DIVISION	CLACKAMAS, COUNTY OF	3/15/2014 7:21 AM
Contacts	Authorizing Official	Insert			EDWARDS, DAVID FQHC DIRECTOR 5037425325	10/14/2013 11:26 AM
Contacts	Primary Contact	Insert			EDWARDS, DAVID FQHC DIRECTOR 5037425325	10/14/2013 11:26 AM
Details	Last Recertification Date	Update			4/1/2013 12:00:00 AM	3/19/2013 11:57 AM
Details	Last Recertification Date	Insert				11/22/2010 8:40 AM
Details	Grant Number	Insert			H80CS00547	11/22/2010 8:40 AM
Details	340B ID	Insert			CH10131E	11/22/2010 8:40 AM
Details	Is Authorizing Official EHB Data	Insert				11/22/2010 8:40 AM
Dates	Last Date That 340B Drugs Purchased	Insert				11/22/2010 8:40 AM
Details	Medicare Provider Number	Insert				11/22/2010 8:40 AM
Details	Entity Name	Insert			CLACKAMAS COUNTY COMMUNITY HEALTH DIVISION	11/22/2010 8:40 AM
Details	Program Code	Insert			CH	11/22/2010 8:40 AM
Details	Entity Subname	Insert			STEWART COMMUNITY CENTER	11/22/2010 8:40 AM
Dates	Participating Approval Date	Insert			11/22/2010 12:00:00 AM	11/22/2010 8:40 AM
Details	State	Insert			Active	11/22/2010 8:40 AM
Dates	Registration Date	Insert			11/19/2010 12:00:00 AM	11/22/2010 8:40 AM
Dates	Signed By Date	Insert			11/1/2010 12:00:00 AM	11/22/2010 8:40 AM
Dates	Start Date	Insert			1/1/2011 12:00:00 AM	11/22/2010 8:40 AM
Terminations	Termination Comments	Insert				11/22/2010 8:40 AM
Terminations	Termination Date	Insert				11/22/2010 8:40 AM
Terminations	Termination Effective Date	Insert				11/22/2010 8:40 AM
Terminations	Termination Reason	Insert				11/22/2010 8:40 AM

340B Drug Pricing Program Database