Covered Entity Details

CHC24115-00 SABAN FREE CLINIC, THE (Active) - information as of 4/25/2025 8:33:11 PM

Main Details

Name

SABAN FREE CLINIC, THE

Subdivision Name

Beverly Health Center

Type

HRSA-Funded Health Center

Site ID

BPS-H80-011780

340B ID

CHC24115-00

Grant Number

H80CS24115

Additional Details

Current Program Status

Active

Registration Date

8/17/2012

Participating Start Date

10/1/2012

Participating Approval Date

9/11/2012

Last Recertification Date

2/10/2025

Contacts

Authorizing Official

Saban Community Clinic
Muriel Nouwezem, CEO
(323) 337-1707

Primary Contact

Saban Free CLinic
Raed Ahmed, Pharmacy Services Manager
(323) 337-1812

Addresses

Street Address

8405 Beverly Blvd.
Los Angeles, CA 90048-3401

Billing Address
Same as Street Address

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

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
CA	2552442,5672442	1194893248,1558740852,1669998845,1235271065,1336281179

Shipping Addresses

Shipping Address 1

Saban Community Clinic Pharmacy
8405 Beverly Blvd.
Los Angeles, CA 90048

Shipping Address 2

Saban Community clinic Pharmacy
5205 Melrose Avenue
Los Angeles, CA 90038

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACARIAHEALTH PHARMACY #13, INC	3302 GARFIELD AVE.		COMMERCE	CA	90040-3102	10/11/2021	01/01/2022	09/30/2023	11/16/2023
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/14/2020	10/01/2020		10/01/2020
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/14/2020	10/01/2020		10/01/2020
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/14/2020	10/01/2020		10/01/2020
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/14/2020	10/01/2020		10/01/2020
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/14/2020	10/01/2020		10/01/2020
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/14/2020	10/01/2020		10/01/2020
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/14/2020	10/01/2020		10/01/2020
Contract Detail	CAREMARK PUERTO RICO SPECIALTY PHARMACY,	CAREMARK PUERTO RICO SPECIALTY PHARMACY	6020 AVE ROBERTO SANCHEZ VILELLA	CAROLINA	PR	00982	07/14/2020	10/01/2020		10/01/2020
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/14/2020	10/01/2020		10/01/2020
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/14/2020	10/01/2020		10/01/2020
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/14/2020	10/01/2020		10/01/2020
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/14/2020	10/01/2020		10/01/2020
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09660	3751 WILSHIRE BOULEVARD	LOS ANGELES	CA	90010	07/12/2018	10/01/2018	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09686	4707 VENICE BLVD	LOS ANGELES	CA	90019	10/12/2018	01/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09732	861 NORTH VINE STREET	HOLLYWOOD	CA	90038	10/12/2018	01/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17004	7100 SANTA MONICA BLVD	WEST HOLLYWOOD	CA	90046	10/12/2018	01/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09626	1701 SOUTH WESTERN AVENUE	LOS ANGELES	CA	90006	10/12/2018	01/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10433	6201 HOLLYWOOD BLVD, STE 126	LOS ANGELES	CA	90028	10/12/2018	01/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09661	6360 WEST THIRD STREET	LOS ANGELES	CA	90036	10/12/2018	01/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09582	3741 CRENSHAW BOULEVARD	LOS ANGELES	CA	90016	10/12/2018	01/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09652	8491 SANTA MONICA BLVD	WEST HOLLYWOOD	CA	90069	10/12/2018	01/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09624	1747 NORTH CAHUENGA BOULEVARD	HOLLYWOOD	CA	90028	10/12/2018	01/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08837	222 N. MARKET ST.	INGLEWOOD	CA	90301	10/12/2018	01/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #4019	5837 S. CENTRAL AVE.	LOS ANGELES	CA	90001	04/11/2019	07/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08889	12618 STUDEBAKER ROAD	NORWALK	CA	90650	04/11/2019	07/01/2019	06/11/2020	07/14/2020
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08879	8985 VENICE BOULEVARD	LOS ANGELES	CA	90034	04/11/2019	07/01/2019	06/11/2020	07/14/2020
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08847	3010 SOUTH SEPULVEDA BOULEVARD	LOS ANGELES	CA	90034	04/11/2019	07/01/2019	06/11/2020	07/14/2020
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08886	8601 SOUTH SEPULVEDA BOULEVARD	LOS ANGELES	CA	90045	04/11/2019	07/01/2019	06/11/2020	07/14/2020
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09493	12315 VENICE BOULEVARD	MAR VISTA	CA	90066	04/11/2019	07/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08871	13171 MINDANAO WAY	MARINA DEL REY	CA	90292	04/11/2019	07/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 04792	15232 SHERMAN WAY	VAN NUYS	CA	91405	04/11/2019	07/01/2019	06/11/2020	07/14/2020
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08853	1645 EAST 103RD STREET	LOS ANGELES	CA	90002	04/11/2019	07/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 05828	1001 WESTWOOD BLVD.	LOS ANGELES	CA	90024	04/11/2019	07/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09689	950 WEST FOOTHILL BLVD	MONROVIA	CA	91016	04/11/2019	07/01/2019	09/30/2023	11/16/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16061	10621 CARMENITA RD	SANTA FE SPRINGS	CA	90670	04/11/2019	07/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09707	14735 VENTURA BLVD.	SHERMAN OAKS	CA	91403	04/11/2019	07/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09634	2521 EAST AVENUE S	PALMDALE	CA	93550	04/11/2019	07/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09767	9045 WILSHIRE BOULEVARD	BEVERLY HILLS	CA	90211	04/11/2019	07/01/2019	04/12/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09666	2419 WORKMAN STREET	LOS ANGELES	CA	90031	04/11/2019	07/01/2019	04/12/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09576	10889 WELLWORTH AVENUE	LOS ANGELES	CA	90024	04/11/2019	07/01/2019	06/11/2020	07/14/2020
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09674	1050 W. SUNSET BOULEVARD	LOS ANGELES	CA	90012	04/11/2019	07/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09721	1401 S. BALDWIN AVE.	ARCADIA	CA	91007	04/11/2019	07/01/2019	06/11/2020	07/14/2020
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09580	5101 OBAMA BLVD	LOS ANGELES	CA	90016	04/11/2019	07/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16319	777 E COLORADO BLVD	PASADENA	CA	91101	04/11/2019	07/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09848	20 E ORANGE GROVE BLVD.	PASADENA	CA	91103	04/11/2019	07/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09669	2530 GLENDALE BOULEVARD	LOS ANGELES	CA	90039	04/11/2019	07/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10146	12746 W. JEFFERSON BLVD., SUITE 3160	PLAYA VISTA	CA	90094	04/11/2019	07/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09791	2532 W. VALLEY BLVD.	ALHAMBRA	CA	91803	04/11/2019	07/01/2019	06/11/2020	07/14/2020
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09608	2505 SANTA MONICA BOULEVARD	SANTA MONICA	CA	90404	04/11/2019	07/01/2019	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09726	1411 LINCOLN BOULEVARD	SANTA MONICA	CA	90401	04/11/2019	07/01/2019	09/30/2023	11/16/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY # 3055	38012 47TH STREET EAST	PALMDALE	CA	93552	10/14/2019	01/01/2020	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY #10292	4030 SOUTH WESTERN AVE.	LOS ANGELES	CA	90062	01/13/2020	04/01/2020	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09584	4345 WEST CENTURY BOULEVARD	INGLEWOOD	CA	90304	01/13/2020	04/01/2020	12/10/2021	02/25/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08892	5822 SOUTH VERMONT AVENUE	LOS ANGELES	CA	90044	07/14/2020	10/01/2020	12/10/2021	02/25/2022
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09558	320 S TWIN OAKS VALLEY RD	SAN MARCOS	CA	92078	04/11/2019	07/01/2019	09/30/2023	11/16/2023
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09656	2771 4TH ST	SANTA ROSA	CA	95405	10/14/2019	01/01/2020	09/30/2023	11/16/2023
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09144	7021 HOLLYWOOD BLVD	LOS ANGELES	CA	90028	01/13/2020	04/01/2020	09/30/2023	11/16/2023
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09527	12100 VENTURA BLVD	STUDIO CITY	CA	91604	01/13/2020	04/01/2020	09/30/2023	11/16/2023
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/14/2020	10/01/2020		10/01/2020
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/14/2020	10/01/2020	09/30/2023	11/16/2023
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/14/2020	10/01/2020	09/30/2023	11/16/2023
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	07/14/2020	10/01/2020		10/01/2020
Contract Detail	RALPHS GROCERY CO	DBA RALPHS #32	3410 W 3RD STREET	LOS ANGELES	CA	90020	07/17/2017	10/01/2017	09/30/2023	11/16/2023
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #2261	3461 WEST THIRD STREET	LOS ANGELES	CA	90005	07/17/2017	10/01/2017	09/30/2023	11/16/2023
Contract Detail	THE VONS COMPANIES INC	PAVILIONS PHARMACY #2739	8969 SANTA MONICA BLVD	WEST HOLLYWOOD	CA	90069	07/17/2017	10/01/2017	09/30/2023	11/16/2023
Contract Detail	THRIFTY PAYLESS INC.	RITE AID #6491	6726 WEST SUNSET BLVD	LOS ANGELES	CA	90028	07/18/2017	10/01/2017	03/09/2018	06/07/2018
Contract Detail	THRIFTY PAYLESS INC.	RITE AID #5458	3550 SOUTH LA BREA AVENUE	LOS ANGELES	CA	90016	07/18/2017	10/01/2017	03/09/2018	06/07/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5425	334 SOUTH VERMONT AVENUE	LOS ANGELES	CA	90020	07/18/2017	10/01/2017	09/30/2023	11/16/2023
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5452	7900 WEST SUNSET BOULEVARD	LOS ANGELES	CA	90046	07/18/2017	10/01/2017	07/09/2018	10/08/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5438	6130 W SUNSET BOULEVARD	HOLLYWOOD	CA	90028	07/18/2017	10/01/2017	03/09/2018	06/07/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5439	4633 SANTA MONICA BLVD.	LOS ANGELES	CA	90029	07/18/2017	10/01/2017	07/09/2018	10/08/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5436	1841 NORTH WESTERN AVENUE	LOS ANGELES	CA	90027	07/18/2017	10/01/2017	09/30/2023	11/16/2023
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5434	1433 GLENDALE BOULEVARD	LOS ANGELES	CA	90026	07/18/2017	10/01/2017	03/09/2018	06/07/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05879	3201 WEST 6TH ST	LOS ANGELES	CA	90020	07/14/2017	10/01/2017		10/01/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07036	5451 W SUNSET BLVD	LOS ANGELES	CA	90027-5613	07/14/2017	10/01/2017		10/01/2017
Contract Detail	WALGREEN CO.	W002 DBA: WALGREENS #15278	1501 VINE ST.	LOS ANGELES	CA	90028-7304	07/14/2017	10/01/2017	02/28/2022	02/28/2022
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #15294	8490 SANTA MONICA BLVD STE 1	WEST HOLLYWOOD	CA	90069	07/14/2017	10/01/2017		10/01/2017
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #15190	1399 ROXBURY DR	LOS ANGELES	CA	90035	10/08/2018	01/01/2019		01/01/2019
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16368	3745 S LA BREA AVE STE C & D	LOS ANGELES	CA	90016	01/10/2019	04/01/2019		04/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06445	8770 W PICO BLVD	LOS ANGELES	CA	90035	07/14/2020	10/01/2020		10/01/2020
Contract Detail	WALGREEN CO.	DBA WALGREENS #12057	1050 N. HIGHLAND AVE.	LOS ANGELES	CA	90038	10/12/2022	01/01/2023		01/01/2023
Contract Detail	WELLPARTNER, INC	20800 SW 115TH AVE	SUITE 100	TUALATIN	OR	97062	07/18/2017	10/01/2017	07/03/2018	08/24/2018

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CHC24115-00	Active	BPS-H80-011780	SABAN FREE CLINIC, THE	Beverly Health Center	8405 Beverly Blvd.	Los Angeles	CA
CHC24115-01	Active	BPS-H80-011779	SABAN FREE CLINIC, THE	S. Mark Taper Foundation Health Center	6043 Hollywood Blvd.	Los Angeles	CA
CHC24115-02	Active	BPS-H80-011778	SABAN FREE CLINIC, THE	Hollywood Wilshire Health Center and Wallis Annenberg Children & Family Health Center	5205 Melrose Ave.	Los Angeles	CA
CHC24115-03	Active	BPS-H80-028381	Los Angeles Free Clinic., The	The Center at Blessed Sacrament	6636 Selma Ave	Los Angeles	CA
CHC24115-04	Active	BPS-H80-030157	Los Angeles Free Clinic., The	The Virgil	137 N Virgil Ave	Los Angeles	CA
CHC24115-05	Active	BPS-H80-034741	Los Angeles Free Clinic., The	Saban Community Clinic - Mobile Clinic Site	6043 Hollywood Blvd.	Los Angeles	CA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CHC24115-00	ACARIAHEALTH PHARMACY #13, INC	3302 GARFIELD AVE.		COMMERCE	CA	90040-3102	01/01/2022	09/30/2023
CHC24115-00	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	10/01/2020
CHC24115-00	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	10/01/2020
CHC24115-00	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	10/01/2020
CHC24115-00	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	10/01/2020
CHC24115-00	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	10/01/2020
CHC24115-00	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	10/01/2020
CHC24115-00	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	10/01/2020
CHC24115-00	CAREMARK PUERTO RICO SPECIALTY PHARMACY,	CAREMARK PUERTO RICO SPECIALTY PHARMACY	6020 AVE ROBERTO SANCHEZ VILELLA	CAROLINA	PR	00982	10/01/2020
CHC24115-00	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	10/01/2020
CHC24115-00	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	10/01/2020
CHC24115-00	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	10/01/2020
CHC24115-00	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	10/01/2020
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09660	3751 WILSHIRE BOULEVARD	LOS ANGELES	CA	90010	10/01/2018	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09686	4707 VENICE BLVD	LOS ANGELES	CA	90019	01/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09732	861 NORTH VINE STREET	HOLLYWOOD	CA	90038	01/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17004	7100 SANTA MONICA BLVD	WEST HOLLYWOOD	CA	90046	01/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09626	1701 SOUTH WESTERN AVENUE	LOS ANGELES	CA	90006	01/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10433	6201 HOLLYWOOD BLVD, STE 126	LOS ANGELES	CA	90028	01/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09661	6360 WEST THIRD STREET	LOS ANGELES	CA	90036	01/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09582	3741 CRENSHAW BOULEVARD	LOS ANGELES	CA	90016	01/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09652	8491 SANTA MONICA BLVD	WEST HOLLYWOOD	CA	90069	01/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09624	1747 NORTH CAHUENGA BOULEVARD	HOLLYWOOD	CA	90028	01/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08837	222 N. MARKET ST.	INGLEWOOD	CA	90301	01/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #4019	5837 S. CENTRAL AVE.	LOS ANGELES	CA	90001	07/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08889	12618 STUDEBAKER ROAD	NORWALK	CA	90650	07/01/2019	06/11/2020
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08879	8985 VENICE BOULEVARD	LOS ANGELES	CA	90034	07/01/2019	06/11/2020
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08847	3010 SOUTH SEPULVEDA BOULEVARD	LOS ANGELES	CA	90034	07/01/2019	06/11/2020
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08886	8601 SOUTH SEPULVEDA BOULEVARD	LOS ANGELES	CA	90045	07/01/2019	06/11/2020
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09493	12315 VENICE BOULEVARD	MAR VISTA	CA	90066	07/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08871	13171 MINDANAO WAY	MARINA DEL REY	CA	90292	07/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 04792	15232 SHERMAN WAY	VAN NUYS	CA	91405	07/01/2019	06/11/2020
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08853	1645 EAST 103RD STREET	LOS ANGELES	CA	90002	07/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 05828	1001 WESTWOOD BLVD.	LOS ANGELES	CA	90024	07/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09689	950 WEST FOOTHILL BLVD	MONROVIA	CA	91016	07/01/2019	09/30/2023
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16061	10621 CARMENITA RD	SANTA FE SPRINGS	CA	90670	07/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09707	14735 VENTURA BLVD.	SHERMAN OAKS	CA	91403	07/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09634	2521 EAST AVENUE S	PALMDALE	CA	93550	07/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09767	9045 WILSHIRE BOULEVARD	BEVERLY HILLS	CA	90211	07/01/2019	04/12/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09666	2419 WORKMAN STREET	LOS ANGELES	CA	90031	07/01/2019	04/12/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09576	10889 WELLWORTH AVENUE	LOS ANGELES	CA	90024	07/01/2019	06/11/2020
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09674	1050 W. SUNSET BOULEVARD	LOS ANGELES	CA	90012	07/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09721	1401 S. BALDWIN AVE.	ARCADIA	CA	91007	07/01/2019	06/11/2020
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09580	5101 OBAMA BLVD	LOS ANGELES	CA	90016	07/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16319	777 E COLORADO BLVD	PASADENA	CA	91101	07/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09848	20 E ORANGE GROVE BLVD.	PASADENA	CA	91103	07/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09669	2530 GLENDALE BOULEVARD	LOS ANGELES	CA	90039	07/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10146	12746 W. JEFFERSON BLVD., SUITE 3160	PLAYA VISTA	CA	90094	07/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09791	2532 W. VALLEY BLVD.	ALHAMBRA	CA	91803	07/01/2019	06/11/2020
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09608	2505 SANTA MONICA BOULEVARD	SANTA MONICA	CA	90404	07/01/2019	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09726	1411 LINCOLN BOULEVARD	SANTA MONICA	CA	90401	07/01/2019	09/30/2023
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY # 3055	38012 47TH STREET EAST	PALMDALE	CA	93552	01/01/2020	12/10/2021
CHC24115-02	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY # 3055	38012 47TH STREET EAST	PALMDALE	CA	93552	04/01/2020	12/10/2021
CHC24115-01	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY # 3055	38012 47TH STREET EAST	PALMDALE	CA	93552	04/01/2020	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY #10292	4030 SOUTH WESTERN AVE.	LOS ANGELES	CA	90062	04/01/2020	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09584	4345 WEST CENTURY BOULEVARD	INGLEWOOD	CA	90304	04/01/2020	12/10/2021
CHC24115-04	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08892	5822 SOUTH VERMONT AVENUE	LOS ANGELES	CA	90044	10/01/2020	12/10/2021
CHC24115-00	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08892	5822 SOUTH VERMONT AVENUE	LOS ANGELES	CA	90044	10/01/2020	12/10/2021
CHC24115-00	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09558	320 S TWIN OAKS VALLEY RD	SAN MARCOS	CA	92078	07/01/2019	09/30/2023
CHC24115-00	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09656	2771 4TH ST	SANTA ROSA	CA	95405	01/01/2020	09/30/2023
CHC24115-00	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09144	7021 HOLLYWOOD BLVD	LOS ANGELES	CA	90028	04/01/2020	09/30/2023
CHC24115-00	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09527	12100 VENTURA BLVD	STUDIO CITY	CA	91604	04/01/2020	09/30/2023
CHC24115-03	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09144	7021 HOLLYWOOD BLVD	LOS ANGELES	CA	90028	07/01/2020	09/30/2023
CHC24115-05	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09144	7021 HOLLYWOOD BLVD	LOS ANGELES	CA	90028	10/01/2022	09/30/2023
CHC24115-00	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	10/01/2020
CHC24115-00	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	10/01/2020	09/30/2023
CHC24115-00	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	10/01/2020	09/30/2023
CHC24115-00	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	10/01/2020
CHC24115-00	RALPHS GROCERY CO	DBA RALPHS #32	3410 W 3RD STREET	LOS ANGELES	CA	90020	10/01/2017	09/30/2023
CHC24115-00	THE VONS COMPANIES INC	VONS PHARMACY #2261	3461 WEST THIRD STREET	LOS ANGELES	CA	90005	10/01/2017	09/30/2023
CHC24115-00	THE VONS COMPANIES INC	PAVILIONS PHARMACY #2739	8969 SANTA MONICA BLVD	WEST HOLLYWOOD	CA	90069	10/01/2017	09/30/2023
CHC24115-00	THRIFTY PAYLESS INC.	RITE AID #6491	6726 WEST SUNSET BLVD	LOS ANGELES	CA	90028	10/01/2017	03/09/2018
CHC24115-00	THRIFTY PAYLESS INC.	RITE AID #5458	3550 SOUTH LA BREA AVENUE	LOS ANGELES	CA	90016	10/01/2017	03/09/2018
CHC24115-00	THRIFTY PAYLESS, INC.	RITE AID #5425	334 SOUTH VERMONT AVENUE	LOS ANGELES	CA	90020	10/01/2017	09/30/2023
CHC24115-00	THRIFTY PAYLESS, INC.	RITE AID #5452	7900 WEST SUNSET BOULEVARD	LOS ANGELES	CA	90046	10/01/2017	07/09/2018
CHC24115-00	THRIFTY PAYLESS, INC.	RITE AID #5438	6130 W SUNSET BOULEVARD	HOLLYWOOD	CA	90028	10/01/2017	03/09/2018
CHC24115-00	THRIFTY PAYLESS, INC.	RITE AID #5439	4633 SANTA MONICA BLVD.	LOS ANGELES	CA	90029	10/01/2017	07/09/2018
CHC24115-00	THRIFTY PAYLESS, INC.	RITE AID #5436	1841 NORTH WESTERN AVENUE	LOS ANGELES	CA	90027	10/01/2017	09/30/2023
CHC24115-00	THRIFTY PAYLESS, INC.	RITE AID #5434	1433 GLENDALE BOULEVARD	LOS ANGELES	CA	90026	10/01/2017	03/09/2018
CHC24115-00	WALGREEN CO.	DBA: WALGREENS # 05879	3201 WEST 6TH ST	LOS ANGELES	CA	90020	10/01/2017
CHC24115-00	WALGREEN CO.	DBA: WALGREENS # 07036	5451 W SUNSET BLVD	LOS ANGELES	CA	90027-5613	10/01/2017
CHC24115-00	WALGREEN CO.	W002 DBA: WALGREENS #15278	1501 VINE ST.	LOS ANGELES	CA	90028-7304	10/01/2017	02/28/2022
CHC24115-00	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #15294	8490 SANTA MONICA BLVD STE 1	WEST HOLLYWOOD	CA	90069	10/01/2017
CHC24115-00	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #15190	1399 ROXBURY DR	LOS ANGELES	CA	90035	01/01/2019
CHC24115-00	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16368	3745 S LA BREA AVE STE C & D	LOS ANGELES	CA	90016	04/01/2019
CHC24115-00	WALGREEN CO.	DBA: WALGREENS # 06445	8770 W PICO BLVD	LOS ANGELES	CA	90035	10/01/2020
CHC24115-00	WALGREEN CO.	DBA WALGREENS #12057	1050 N. HIGHLAND AVE.	LOS ANGELES	CA	90038	01/01/2023
CHC24115-00	WELLPARTNER, INC	20800 SW 115TH AVE	SUITE 100	TUALATIN	OR	97062	10/01/2017	07/03/2018

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	2/14/2024 9:33:20 AM	2/10/2025 10:11:25 PM	2/10/2025 10:11 PM
Contacts	Authorizing Official	Update	Profile Change Request	Nouwezem, Muriel Interim CEO Saban Community Clinic 3233371707	Nouwezem, Muriel CEO Saban Community Clinic 3233371707	2/14/2024 9:44 AM
Details	Last Recertification Date	Update	Recertification	1/30/2023 10:08:47 PM	2/14/2024 9:33:20 AM	2/14/2024 9:33 AM
Details	Last Recertification Date	Update	Recertification	1/31/2022 1:15:56 PM	1/30/2023 10:08:47 PM	1/30/2023 10:08 PM
Details	Last Recertification Date	Update	Recertification	2/8/2021 9:24:34 AM	1/31/2022 1:15:56 PM	1/31/2022 1:15 PM
Addresses	Shipping Address	Insert	Recertification		Saban Community Clinic Pharmacy 8405 Beverly Blvd. Los Angeles, CA 90048	2/8/2021 9:24 AM
Addresses	Shipping Address	Insert	Recertification		Saban Community clinic Pharmacy 5205 Melrose Avenue Los Angeles, CA 90038	2/8/2021 9:24 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/8/2021 9:24 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		2552442	2/8/2021 9:24 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	2/8/2021 9:24 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/8/2021 9:24 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		5672442	2/8/2021 9:24 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	2/8/2021 9:24 AM
Medicaid Billing	NPI: State	Update	Recertification		CA	2/8/2021 9:24 AM
Medicaid Billing	NPI: State	Update	Recertification		CA	2/8/2021 9:24 AM
Medicaid Billing	NPI: State	Update	Recertification		CA	2/8/2021 9:24 AM
Medicaid Billing	NPI: State	Update	Recertification		CA	2/8/2021 9:24 AM
Medicaid Billing	NPI: State	Update	Recertification		CA	2/8/2021 9:24 AM
Details	Last Recertification Date	Update	Recertification	1/28/2020 3:29:26 PM	2/8/2021 9:24:34 AM	2/8/2021 9:24 AM
Details	Last Recertification Date	Update	Recertification	1/31/2019 1:42:25 AM	1/28/2020 3:29:26 PM	1/28/2020 3:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1235271065	4/6/2019 12:46 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1336281179	4/6/2019 12:46 AM
Details	Last Recertification Date	Update	Recertification	2/14/2018 1:35:19 PM	1/31/2019 1:42:25 AM	1/31/2019 1:42 AM
Contacts	Primary Contact	Update	Change Request	Normand, Elisabeth Director of Pharmacy Saban Community Clinic 3233371812	Ahmed, Raed Pharmacy Services Manager Saban Free CLinic 3233371812	8/20/2018 1:44 PM
Contacts	Authorizing Official	Update	AO Change Request	Hudman, Julie CEO Saban Community Clinic 3233301660	Nouwezem, Muriel Interim CEO Saban Community Clinic 3233371707	7/16/2018 3:02 PM
Details	Last Recertification Date	Update	Recertification	2/16/2017 12:00:00 AM	2/14/2018 1:35:19 PM	2/14/2018 1:35 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1669998845	1/30/2018 11:58 PM
Contacts	Authorizing Official	Update		Hudman, Julie CEO 3233301660	Hudman, Julie CEO Saban Community Clinic 3233301660	1/30/2018 11:52 PM
Contacts	Primary Contact	Update		Normand, Elisabeth Director of Pharmacy 3233371812	Normand, Elisabeth Director of Pharmacy Saban Community Clinic 3233371812	9/29/2017 12:06 PM
Contacts	Primary Contact	Insert			Normand, Elisabeth Director of Pharmacy 3233371812	8/9/2017 5:07 PM
Contacts	Authorizing Official	Update		BUJER, JEFFREY CEO 3233301660	Hudman, Julie CEO 3233301660	8/9/2017 5:07 PM
Contacts	Signed By	Insert			Sergeyev, Sergey Chief Operations and Financial Officer 3233301638	8/9/2017 5:07 PM
Addresses	Main Address	Insert			8405 Beverly Blvd. Los Angeles, CA 90048-3401	2/17/2017 12:21 AM
Details	Last Recertification Date	Update		2/25/2016 12:00:00 AM	2/16/2017 12:00:00 AM	2/17/2017 12:21 AM
Medicaid Billing	NPI: Number	Insert			1558740852	10/26/2016 7:40 PM
Details	Last Recertification Date	Update		3/2/2015 12:00:00 AM	2/25/2016 12:00:00 AM	2/25/2016 1:29 PM
Contacts	Authorizing Official	Update		Bujer, Jeffrey CEO 3233301660	BUJER, JEFFREY CEO 3233301660	6/4/2015 2:08 PM
Details	Last Recertification Date	Update		3/23/2014 12:00:00 AM	3/2/2015 12:00:00 AM	3/2/2015 10:17 AM
Details	Last Recertification Date	Update		4/1/2013 12:00:00 AM	3/23/2014 12:00:00 AM	3/23/2014 3:25 PM
Details	Entity Name	Update		The Saban Free Clinic	SABAN FREE CLINIC, THE	3/23/2014 3:25 PM
Contacts	Authorizing Official	Insert			Bujer, Jeffrey CEO 3233301660	11/22/2013 8:14 AM
Details	Last Recertification Date	Update			4/1/2013 12:00:00 AM	2/21/2013 12:56 PM
Details	340B ID	Update		IS-FF-CHC24115-00	CHC24115-00	9/11/2012 5:11 PM
Dates	Participating Approval Date	Update			9/11/2012 12:00:00 AM	9/11/2012 5:11 PM
Details	State	Update		Pending	Active	9/11/2012 5:11 PM
Dates	Start Date	Update			10/1/2012 12:00:00 AM	9/11/2012 5:11 PM
Details	340B ID	Update		ONLINE_REG	IS-FF-CHC24115-00	9/5/2012 4:05 PM
Details	Entity Name	Update		Los Angeles Free Clinic dba The Saban Free Clinic	The Saban Free Clinic	9/5/2012 4:05 PM
Details	Entity Subname	Update			Beverly Health Center	9/5/2012 4:05 PM
Medicaid Billing	NPI: Number	Insert			1194893248	8/17/2012 1:54 PM
Details	Last Recertification Date	Insert				8/17/2012 1:54 PM
Details	Grant Number	Insert			H80CS24115	8/17/2012 1:54 PM
Details	340B ID	Insert			ONLINE_REG	8/17/2012 1:54 PM
Details	Is Authorizing Official EHB Data	Insert				8/17/2012 1:54 PM
Dates	Last Date That 340B Drugs Purchased	Insert				8/17/2012 1:54 PM
Details	Medicare Provider Number	Insert				8/17/2012 1:54 PM
Details	Entity Name	Insert			Los Angeles Free Clinic dba The Saban Free Clinic	8/17/2012 1:54 PM
Details	Program Code	Insert			CH	8/17/2012 1:54 PM
Details	Entity Subname	Insert				8/17/2012 1:54 PM
Dates	Participating Approval Date	Insert				8/17/2012 1:54 PM
Details	State	Insert			Pending	8/17/2012 1:54 PM
Dates	Registration Date	Insert			8/17/2012 12:00:00 AM	8/17/2012 1:54 PM
Dates	Signed By Date	Insert			8/17/2012 12:00:00 AM	8/17/2012 1:54 PM
Dates	Start Date	Insert				8/17/2012 1:54 PM
Terminations	Termination Comments	Insert				8/17/2012 1:54 PM
Terminations	Termination Date	Insert				8/17/2012 1:54 PM
Terminations	Termination Effective Date	Insert				8/17/2012 1:54 PM
Terminations	Termination Reason	Insert				8/17/2012 1:54 PM

340B Drug Pricing Program Database