Covered Entity Details

CH01143AA Lynn Community Health Center, Inc (Active) - information as of 6/6/2025 12:38:33 PM

Main Details

Name

Lynn Community Health Center, Inc

Subdivision Name

Program for All-Inclusive Care for the Elderly (PACE) Site

Type

HRSA-Funded Health Center

Site ID

BPS-H80-004331

340B ID

CH01143AA

Grant Number

H80CS00624

Additional Details

Current Program Status

Active

Registration Date

6/27/2012

Participating Start Date

10/1/2012

Participating Approval Date

8/13/2012

Last Recertification Date

2/19/2025

Contacts

Authorizing Official

Lynn Community Health, Inc
Ryan K Sullivan, Chief Financial Officer
(959) 216-7305

Primary Contact

Lynn Community Health, Inc
Marina Rabinovich, Director of Pharmacy
(781) 581-3900

Addresses

Street Address

20 School Street
Lynn, MA 01902-2952

Billing Address

Lynn Community Health Center
269 Union Street
Lynn, MA 01901

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
MA	110020830D,110020830B	1013997691

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	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	12/14/2016	01/01/2017	01/01/2017	01/15/2023	03/30/2024
Contract Detail	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	09/05/2012	10/01/2012	04/01/2008	05/08/2019	05/08/2019
Contract Detail	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	09/05/2012	10/01/2012	10/01/2013	01/16/2024	04/22/2025

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH011430	Active	BPS-H80-001516	LYNN COMMUNITY HEALTH, INC.	LYNN COMMUNITY HEALTH CENTER	269 Union St	Lynn	MA
CH01143AA	Active	BPS-H80-004331	Lynn Community Health Center, Inc	Program for All-Inclusive Care for the Elderly (PACE) Site	20 School Street	Lynn	MA
CH01143AB	Active	BPS-H80-003639	Lynn Community Health Center, Inc	Program for All-Inclusive Care for the Elderly (PACE) Site	62 Market Street	Lynn	MA
CH01143AC	Terminated	BPS-H80-000724	Lynn Community Health Center, Inc	Program for All-Inclusive Care for the Elderly (PACE) Site	9 Buffum Street	Lynn	MA
CH01143AD	Active	BPS-H80-009470	Lynn Community Health, Inc.	Lynn Community Health Center- Primary Care and Behavioral Health Services	280 Union Street	Lynn	MA
CH01143AE	Active	BPS-H80-012148	Lynn Community Health Center, Inc	Program for All-Inclusive Care for the Elderly (PACE) Site	37 Friend Street	Lynn	MA
CH01143AF	Active	BPS-H80-012157	Lynn Community Health Center, Inc	Program for All-Inclusive Care for the Elderly (PACE) Site	100 Cummings Center	Beverly	MA
CH01143AG	Active	BPS-H80-012153	LYNN COMMUNITY HEALTH, INC.	Program for All-Inclusive Care for the Elderly (PACE) Site	29 Emerson Ave	Gloucester	MA
CH01143AH	Active	BPS-H80-006546	LYNN COMMUNITY HEALTH, INC.	Lynn Multiservice Center	100 WILLOW ST	LYNN	MA
CH01143AJ	Active	BPS-H80-012570	LYNN COMMUNITY HEALTH, INC.	Cobbet Elementary School School Based Health Center	40 Franklin St	Lynn	MA
CH01143AK	Active	BPS-H80-014049	LYNN COMMUNITY HEALTH, INC.	Tracy Elementary School, School Based Health Center	35 WALNUT ST	LYNN	MA
CH01143AL	Active	BPS-H80-014029	LYNN COMMUNITY HEALTH, INC.	Robert L. Ford School, School Based Health Center	49 HOLLINGSWORTH ST	LYNN	MA
CH01143AM	Active	BPS-H80-014023	LYNN COMMUNITY HEALTH, INC.	Brickett Elementary School, School Based Health Center	123 LEWIS ST	LYNN	MA
CH01143AN	Active	BPS-H80-017967	LYNN COMMUNITY HEALTH, INC.	Julia F. Callahan Elementary School, School Based Health Center	200 Ocallaghan Way	Lynn	MA
CH01143AP	Active	BPS-H80-020804	Lynn Community Health, Inc.	Drewicz Elementary School - School Based Health Center	34 Hood Street Lynn, MA 01905	Lynn	MA
CH01143AQ	Active	BPS-H80-021421	Lynn Community Health, Inc.	Medical Outreach Clinic	73 Buffum Street	Lynn	MA
CH01143AR	Active	BPS-H80-024622	Lynn Community Health, Inc.	Washington Elementary School, School Based Health Center	58 Blossom St	Lynn	MA
CH01143AS	Active	BPS-H80-028182	Lynn Community Health, Inc.	Lynn Vocational Technical High School, School Based Health Center, Annex	90 Commercial St	Lynn	MA
CH01143AT	Active	BPS-H80-028040	Lynn Community Health, Inc.	William R Fallon Elementary School, School Based Health Center	100 Robinson St	Lynn	MA
CH01143AU	Active	BPS-H80-029660	Lynn Community Health, Inc.	Fecteau - Leary Junior / Senior High School	33 North Common Street	Lynn	MA
CH01143P	Active	BPS-H80-001100	LYNN COMMUNITY HEALTH CENTER, INC	MARKET SQUARE FAMILY HEALTH SERVICES	29 MARKET SQUARE	LYNN	MA
CH01143Q	Active	BPS-H80-002601	LYNN COMMUNITY HEALTH, INC.	MSFHS AT WESTERN AVENUE	694 Western Ave	Lynn	MA
CH01143R	Active	BPS-H80-005707	Lynn Community Health Center, Inc	Lynn Vocational Technical High School Based Health Center	80 Neptune Boulevard	Lynn	MA
CH01143S	Active	BPS-H80-005961	LYNN COMMUNITY HEALTH, INC.	LYNN ENGLISH HIGH SCHOOL SBHC	50 Goodridge St	Lynn	MA
CH01143T	Active	BPS-H80-006156	LYNN COMMUNITY HEALTH, INC.	CLASSICAL HIGH SCHOOL SBHC	235 Ocallaghan Way	Lynn	MA
CH01143U	Active	BPS-H80-007491	LYNN COMMUNITY HEALTH, INC.	BREED MIDDLE SCHOOL SBHC	90 Ocallaghan Way	Lynn	MA
CH01143V	Active	BPS-H80-017966	LYNN COMMUNITY HEALTH, INC.	THURGOOD MARSHALL MIDDLE SCHOOL SBHC	74-114 Brookline Street	Lynn	MA
CH01143W	Active	BPS-H80-011468	LYNN COMMUNITY HEALTH, INC.	Lynn Community Health Center Satellite	20 Central Ave	Lynn	MA
CH01143X	Active	BPS-H80-006805	LYNN COMMUNITY HEALTH, INC.	INGALLS ELEMENTARY SCHOOL	1 Collins Street Ter	Lynn	MA
CH01143Y	Active	BPS-H80-010866	Lynn Community Health Center, Inc	Harrington Elementary School - School Based Health Center	21 Dexter Street	Lynn	MA
CH01143Z	Active	BPS-H80-010997	Lynn Community Health Center, Inc	Connery Elementary School - School Based Health Center	50 Elm Street	Lynn	MA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Carve-In Effective Date	Termination Date
CH011430	AHSSHC	EXPEDIEN RX PHARMACY	5050 WESLEY RD STE 120	APOPKA	FL	32712	01/01/2019
CH011430	AZ PHARMACY, LLC	DBA AMAZON PHARMACY #002	3809 E WATKINS ST	PHOENIX	AZ	85034	04/01/2019
CH011430	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH011430	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH011430	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143AD	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143AD	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143AD	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143AH	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143AH	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143AH	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143AJ	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143AJ	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143AJ	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143U	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143U	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143U	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143AM	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143AM	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143AM	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143Z	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143Z	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143Z	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143AP	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143AP	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143AP	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143S	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143S	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143S	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143AL	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143AL	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143AL	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143Y	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143Y	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143Y	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143X	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143X	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143X	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143AN	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143AN	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143AN	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143R	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143R	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143R	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143V	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143V	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143V	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143AK	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143AK	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143AK	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143AR	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143AR	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143AR	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143W	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143W	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143W	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143AQ	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143AQ	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143AQ	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143P	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143P	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143P	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143Q	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143Q	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143Q	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143T	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2019
CH01143T	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2019
CH01143T	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2019
CH01143AS	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	01/01/2020
CH01143AS	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	01/01/2020
CH01143AS	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	01/01/2020
CH01143AT	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2020
CH01143AU	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2020
CH01143AU	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2020
CH01143AT	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/01/2020
CH01143AU	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	04/01/2020
CH01143AT	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	04/01/2020
CH011430	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017	01/15/2023
CH01143P	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017	01/31/2024
CH01143Q	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017	01/31/2024
CH01143W	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017
CH01143R	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017	01/31/2023
CH01143S	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017
CH01143T	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017
CH01143U	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017
CH01143V	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017
CH01143X	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017
CH01143Y	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017
CH01143Z	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017
CH01143AA	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017	01/15/2023
CH01143AB	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017	01/15/2023
CH01143AC	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017	04/01/2021
CH01143AD	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017	01/15/2023
CH01143AE	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017	01/15/2023
CH01143AF	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017	01/15/2023
CH01143AG	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017	01/15/2023
CH01143AH	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/05/2017	07/01/2017	01/15/2023
CH01143AJ	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017	01/15/2023
CH01143AM	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017	01/15/2023
CH01143AL	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017	01/15/2023
CH01143AK	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017	01/15/2023
CH01143AN	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2017	01/01/2017	01/15/2023
CH01143AP	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2018	07/01/2018	01/15/2023
CH01143AQ	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	07/01/2018	07/01/2018	01/15/2023
CH01143AR	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2019	04/01/2019	01/31/2023
CH01143AS	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	01/01/2020	01/01/2020	01/31/2023
CH01143AT	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	04/01/2020	07/01/2020	01/31/2023
CH01143AU	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	04/01/2020	07/01/2020	01/31/2023
CH011430	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	10/01/2010	01/01/2017	01/12/2024
CH011430	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	10/01/2010	07/01/2017	05/08/2019
CH01143P	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	03/17/2008	04/01/2008	05/08/2019
CH01143P	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	10/01/2010	10/01/2013	01/16/2024
CH01143Q	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	10/01/2010	04/01/2008	05/08/2019
CH01143Q	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	10/01/2010	10/01/2013	01/16/2024
CH01143W	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	10/01/2012	04/01/2008	05/08/2019
CH01143W	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	10/01/2012	10/01/2013
CH01143R	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	10/01/2012	04/01/2008	05/08/2019
CH01143R	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	10/01/2012	10/01/2013	01/16/2024
CH01143S	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	10/01/2012	04/01/2008	05/08/2019
CH01143S	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	10/01/2012	10/01/2013
CH01143T	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	10/01/2012	04/01/2008	05/08/2019
CH01143T	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	10/01/2012	10/01/2013	01/16/2024
CH01143U	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	10/01/2012	04/01/2008	05/08/2019
CH01143U	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	10/01/2012	10/01/2013	01/16/2024
CH01143V	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	10/01/2012	04/01/2008	05/08/2019
CH01143V	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	10/01/2012	10/01/2013
CH01143X	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	10/01/2012	04/01/2008	05/08/2019
CH01143X	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	10/01/2012	10/01/2013
CH01143Y	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	10/01/2012	04/01/2008	05/08/2019
CH01143Y	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	10/01/2012	10/01/2013
CH01143Z	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	10/01/2012	04/01/2008	05/08/2019
CH01143Z	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	10/01/2012	10/01/2013
CH01143AA	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	10/01/2012	04/01/2008	05/08/2019
CH01143AA	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	10/01/2012	10/01/2013	01/16/2024
CH01143AB	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	10/01/2012	04/01/2008	05/08/2019
CH01143AB	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	10/01/2012	10/01/2013	01/16/2024
CH01143AC	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	10/01/2012	04/01/2008	05/08/2019
CH01143AC	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	10/01/2012	10/01/2013	04/01/2021
CH01143AD	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	10/01/2012	04/01/2008	05/08/2019
CH01143AD	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	10/01/2012	10/01/2013	01/16/2024
CH01143AE	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	07/01/2017	07/01/2017	05/08/2019
CH01143AE	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	07/01/2017	07/01/2017	01/16/2024
CH01143AF	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	07/01/2017	07/01/2017	01/16/2024
CH01143AF	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	07/01/2017	07/01/2017	05/08/2019
CH01143AG	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	07/01/2017	07/01/2017	01/16/2024
CH01143AG	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	07/01/2017	07/01/2017	05/08/2019
CH01143AH	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	07/01/2017	07/01/2017	01/16/2024
CH01143AH	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	07/01/2017	07/01/2017	05/08/2019
CH01143AJ	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	07/01/2017	07/01/2017	01/16/2024
CH01143AJ	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	07/01/2017	07/01/2017	05/08/2019
CH01143AM	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	07/01/2017	07/01/2017	01/16/2024
CH01143AM	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	07/01/2017	07/01/2017	05/08/2019
CH01143AL	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	07/01/2017	07/01/2017	01/16/2024
CH01143AL	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	07/01/2017	07/01/2017	05/08/2019
CH01143AK	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	07/01/2017	07/01/2017	01/16/2024
CH01143AK	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	07/01/2017	07/01/2017	05/08/2019
CH01143AN	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	07/01/2017	07/01/2017	01/16/2024
CH01143AN	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	07/01/2017	07/01/2017	05/08/2019
CH01143AP	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	01/01/2018	07/01/2018	01/16/2024
CH01143AP	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	01/01/2018	07/01/2018	05/08/2019
CH01143AQ	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	07/01/2018	07/01/2018	01/16/2024
CH01143AQ	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	07/01/2018	07/01/2018	05/08/2019
CH01143AR	D.A.W., LLC.	D/B/A EATON APOTHECARY #2035	12 MARKET SQUARE	LYNN	MA	01905	01/01/2019	04/01/2019	05/08/2019
CH01143AR	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	01/01/2019	04/01/2019	01/16/2024
CH01143AS	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	01/01/2020	01/01/2020	01/16/2024
CH01143AU	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	04/01/2020	07/01/2020	01/16/2024
CH01143AT	D.A.W., LLC.	EATON APOTHECARY #3035	2 CENTENNIAL DR STE 1A	PEABODY	MA	01960	04/01/2020	07/01/2020	01/16/2024
CH01143Q	LYNN COMMUNITY HEALTH	D/B/A LYNN COMMUNITY HEALTH	CENTER PHARMACY 298 UNION STREET	LYNN	MA	01901	10/01/2010		11/03/2017
CH011430	M.N. PHARMACY LLC	DBA AMAZON PHARMACY #003	6701 NW 7TH ST., STE. #199	MIAMI	FL	33126	01/01/2019
CH011430	MHHP ACQUISITION COMPANY, LLC	OMNICARE OF CENTRAL MASSACHUSETTS	574 HARTFORD TURNPIKE	SHREWSBURY	MA	01545	07/01/2018
CH011430	NORTH SHORE PHARMACY SERVICES	OMNICARE OF NORTHERN MASSACHUSETTS	2 TECHNOLOGY DRIVE	PEABODY	MA	01960	07/01/2018
CH011430	PILLPACK LLC	DBA PILLPACK BY AMAZON PHARMACY	250 COMMERCIAL ST STE 2012	MANCHESTER	NH	03101	01/01/2019
CH011430	WALGREEN EASTERN CO. INC.	DBA WALGREENS #13807	89 PLEASANT STREET	MARBLEHEAD	MA	01945	07/01/2013		06/28/2016
CH011430	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 15969	505 PARADISE ROAD	SWAMPSCOTT	MA	01907	07/01/2013
CH011430	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 02063	29 NEW DERBY STREET	SALEM	MA	01970	07/01/2013
CH011430	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 02208	35 MAIN ST	PEABODY	MA	01960	07/01/2013
CH011430	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 02325	290 BROADWAY	LYNN	MA	01904	07/01/2013
CH011430	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #02471	166 WALNUT ST	SAUGUS	MA	01906-1976	07/01/2013
CH011430	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 02517	201 MAIN STREET	GLOUCESTER	MA	01930	07/01/2013
CH011430	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 02577	1228 BROADWAY	SAUGUS	MA	01906	07/01/2013
CH011430	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 02716	21 JOYCE ST	LYNN	MA	01902	07/01/2013
CH011430	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 02823	841 WESTERN AVE	LYNN	MA	01905	07/01/2013
CH011430	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 03130	185 CENTRE STREET	MALDEN	MA	02148	07/01/2013
CH011430	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 03496	317 FERRY ST	EVERETT	MA	02149	07/01/2013
CH011430	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 03508	572 MAIN ST	WAKEFIELD	MA	01880	07/01/2013
CH011430	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 03759	1010 BROADWAY	CHELSEA	MA	02150	07/01/2013
CH011430	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 04393	54 ELLIOTT STREET	BEVERLY	MA	01915	07/01/2013
CH011430	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 04595	59 BOSTON STREET	SALEM	MA	01970	07/01/2013		05/19/2025
CH011430	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 09011	107 HIGH ST	DANVERS	MA	01923-3113	07/01/2013
CH011430	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 10824	430 BROADWAY	REVERE	MA	02151	07/01/2013
CH011430	Walgreens Central Fill #21400	44 Cabot Blvd.		Mansfield	MA	02048	07/01/2023
CH011430	WALGREENS MAIL SERVICE, INC.		8337 S PARK CIRCLE	ORLANDO	FL	32819-9049	07/01/2013		08/03/2015
CH011430	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	07/01/2013		08/03/2015

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	2/23/2024 8:44:55 AM	2/19/2025 10:25:12 AM	2/19/2025 10:25 AM
Contacts	Primary Contact	Update	Group Change Request	Freydin, Elena Chief Compliance Officer Lynn Community Health Center 9788284054	Rabinovich, Marina Director of Pharmacy Lynn Community Health, Inc 7815813900	8/27/2024 9:38 AM
Contacts	Authorizing Official	Update	Profile Change Request	Sullivan, Ryan K Chief Financial Officer Lynn Community Health Center 6173782169	Sullivan, Ryan K Chief Financial Officer Lynn Community Health, Inc 9592167305	8/26/2024 6:41 AM
Details	Last Recertification Date	Update	Recertification	2/13/2023 6:37:42 PM	2/23/2024 8:44:55 AM	2/23/2024 8:44 AM
Contacts	Primary Contact	Update	Change Request	Pechinsky, Geoffrey Alan MD Lynn Community Health Center 8575238388	Freydin, Elena Chief Compliance Officer Lynn Community Health Center 9788284054	1/23/2024 12:17 PM
Contacts	Authorizing Official	Update	Group Change Request	Mahaniah, Kiame Chief Executive Officer Lynn Community Health, Inc. 7815962502-2707	Sullivan, Ryan K Chief Financial Officer Lynn Community Health Center 6173782169	5/18/2023 6:13 PM
Contacts	Primary Contact	Update	Group Change Request	MacLeod, Kim M CFO Lynn Community Health, Inc. 7815962502-2709	Pechinsky, Geoffrey Alan MD Lynn Community Health Center 8575238388	5/18/2023 6:13 PM
Details	Last Recertification Date	Update	Recertification	2/8/2022 12:56:46 PM	2/13/2023 6:37:42 PM	2/13/2023 6:37 PM
Contacts	Primary Contact	Update	Recertification	LeBlanc, Becky Grants Manager Lynn Community Health, Inc. 7815962502-2702	MacLeod, Kim M CFO Lynn Community Health, Inc. 7815962502-2709	2/8/2022 12:56 PM
Details	Last Recertification Date	Update	Recertification	2/17/2021 9:10:02 AM	2/8/2022 12:56:46 PM	2/8/2022 12:56 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1013997691	2/17/2021 9:10 AM
Medicaid Billing	NPI: State	Insert	Recertification		MA	2/17/2021 9:10 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1013997691 ( )		2/17/2021 9:10 AM
Details	Last Recertification Date	Update	Recertification	1/30/2020 11:21:00 AM	2/17/2021 9:10:02 AM	2/17/2021 9:10 AM
Details	Last Recertification Date	Update	Recertification	2/1/2019 9:11:07 AM	1/30/2020 11:21:00 AM	1/30/2020 11:21 AM
Details	Last Recertification Date	Update	Recertification	3/1/2018 8:52:30 AM	2/1/2019 9:11:07 AM	2/1/2019 9:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/13/2018 1:14 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110020830D	12/13/2018 1:14 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	12/13/2018 1:14 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1558588756 ( )		4/4/2018 12:52 PM
Medicaid Billing	Medicaid: Number	Update	Recertification	1301853	110020830B	3/1/2018 8:52 AM
Details	Last Recertification Date	Update	Recertification	1/31/2017 12:00:00 AM	3/1/2018 8:52:30 AM	3/1/2018 8:52 AM
Contacts	Primary Contact	Insert	Change Request		LeBlanc, Becky Grants Manager Lynn Community Health, Inc. 7815962502-2702	9/26/2017 2:05 PM
Contacts	Authorizing Official	Insert	Change Request		Mahaniah, Kiame Chief Executive Officer Lynn Community Health, Inc. 7815962502-2707	9/26/2017 2:05 PM
Contacts	Signed By	Update		Berry, Lori A. Executive Director 7815962502-2707	Berry, Lori A. Executive Director Lynn Community Health Center 7815962502-2707	9/19/2017 11:29 AM
Contacts	Signed By	Insert			Berry, Lori A. Executive Director 7815962502-2707	5/25/2017 9:41 AM
Addresses	Main Address	Insert			20 School Street Lynn, MA 01902-2952	4/25/2017 3:13 PM
Addresses	Billing Address	Insert			Lynn Community Health Center 269 Union Street Lynn, MA 01901	4/25/2017 3:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/25/2017 3:13 PM
Medicaid Billing	Medicaid: Number	Insert			1301853	4/25/2017 3:13 PM
Medicaid Billing	Medicaid: State	Insert			MA	4/25/2017 3:13 PM
Medicaid Billing	NPI: Number	Insert			1013997691	4/25/2017 3:13 PM
Medicaid Billing	NPI: Number	Insert			1558588756	4/25/2017 3:13 PM
Details	Last Recertification Date	Update		2/17/2016 12:00:00 AM	1/31/2017 12:00:00 AM	1/31/2017 2:14 PM
Details	Last Recertification Date	Update		2/3/2015 12:00:00 AM	2/17/2016 12:00:00 AM	2/17/2016 2:48 PM
Details	Last Recertification Date	Update		3/15/2014 12:00:00 AM	2/3/2015 12:00:00 AM	2/3/2015 10:35 AM
Details	Entity Subname	Update		Elder Service Plan of the North Shore	Program for All-Inclusive Care for the Elderly (PACE) Site	6/2/2014 12:41 PM
Details	Last Recertification Date	Update		4/1/2013 12:00:00 AM	3/15/2014 12:00:00 AM	3/15/2014 8:48 AM
Details	Last Recertification Date	Update			4/1/2013 12:00:00 AM	3/4/2013 8:14 AM
Details	340B ID	Update		IS-FF-CH01143AA	CH01143AA	8/13/2012 5:58 PM
Details	Entity Name	Update		Lynn Community Health Center	Lynn Community Health Center, Inc	8/13/2012 5:58 PM
Dates	Participating Approval Date	Update			8/13/2012 12:00:00 AM	8/13/2012 5:58 PM
Details	State	Update		Pending	Active	8/13/2012 5:58 PM
Dates	Start Date	Update			10/1/2012 12:00:00 AM	8/13/2012 5:58 PM
Details	Grant Number	Update		011430	H80CS00624	8/9/2012 7:18 PM
Details	340B ID	Update		ONLINE_REG	IS-FF-CH01143AA	8/9/2012 7:18 PM
Details	Entity Subname	Update		Elder Service Plan of the North Shore - PACE site	Elder Service Plan of the North Shore	8/9/2012 7:18 PM
Details	Last Recertification Date	Insert				6/27/2012 9:28 PM
Details	Grant Number	Insert			011430	6/27/2012 9:28 PM
Details	340B ID	Insert			ONLINE_REG	6/27/2012 9:28 PM
Details	Is Authorizing Official EHB Data	Insert				6/27/2012 9:28 PM
Dates	Last Date That 340B Drugs Purchased	Insert				6/27/2012 9:28 PM
Details	Medicare Provider Number	Insert				6/27/2012 9:28 PM
Details	Entity Name	Insert			Lynn Community Health Center	6/27/2012 9:28 PM
Details	Program Code	Insert			CH	6/27/2012 9:28 PM
Details	Entity Subname	Insert			Elder Service Plan of the North Shore - PACE site	6/27/2012 9:28 PM
Dates	Participating Approval Date	Insert				6/27/2012 9:28 PM
Details	State	Insert			Pending	6/27/2012 9:28 PM
Dates	Registration Date	Insert			6/27/2012 12:00:00 AM	6/27/2012 9:28 PM
Dates	Signed By Date	Insert			6/27/2012 12:00:00 AM	6/27/2012 9:28 PM
Dates	Start Date	Insert				6/27/2012 9:28 PM
Terminations	Termination Comments	Insert				6/27/2012 9:28 PM
Terminations	Termination Date	Insert				6/27/2012 9:28 PM
Terminations	Termination Effective Date	Insert				6/27/2012 9:28 PM
Terminations	Termination Reason	Insert				6/27/2012 9:28 PM

340B Drug Pricing Program Database