Covered Entity Details

CH08090D PEAK VISTA COMMUNITY HEALTH CENTERS (Terminated) - information as of 5/3/2025 11:29:23 PM

Main Details

Name

PEAK VISTA COMMUNITY HEALTH CENTERS

Subdivision Name

Health Center at Kiowa

Type

HRSA-Funded Health Center

Site ID

BPS-H80-014124

340B ID

CH08090D

Grant Number

H80CS00212

Additional Details

Current Program Status

Terminated

Registration Date

9/18/2012

Participating Start Date

1/1/2013

Participating Approval Date

11/16/2012

Last Recertification Date

2/1/2022

Termination Date
Termination Reason

7/1/2022
Site closure

Contacts

Authorizing Official

PVCHC
Lisa Ramey, CMDO
(719) 344-6455

Primary Contact

Peak Vista Community Health Centers
Katie Boudreaux, Vice President of Pharmacy Services
(719) 344-6269

Addresses

Street Address

320 Comanche Street
Kiowa, CO 80117

Billing Address

PEAK VISTA COMMUNITY HEALTH CENTERS
3205 N. Academy Blvd, Suite 130
Colorado Springs, CO 80917

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

Comments

Comment	Last Updated On
8/7/14 PLAINS MEDICAL CENTER merged with PEAK VISTA COMMUNITY HEALTH CENTERS, 340B IDs remain the same but organization name, EIN, grant number, AO and billing organization have changed	08/07/2014

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
CO	03000221,9000143434,67134866,05638267	1205255304,1700834272,1730166034,1912240540

Shipping Addresses

Shipping Address 1

Peak Vista CHC Pharmacy
225 S. Union Blvd
Colorado Springs, CO 80910

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
CH080900	Active	BPS-H80-014122	PEAK VISTA COMMUNITY HEALTH CENTERS	Health Center at Limon	820 1st St	Limon	CO
CH08090B	Active	BPS-H80-014120	PEAK VISTA COMMUNITY HEALTH CENTERS	Dental Center at Flagler	309 PAWNEE AVE	Flagler	CO
CH08090C	Active	BPS-H80-014123	PEAK VISTA COMMUNITY HEALTH CENTERS	Health Center at Strasburg	55981 E COLFAX AVE	STRASBURG	CO
CH08090D	Terminated	BPS-H80-014124	PEAK VISTA COMMUNITY HEALTH CENTERS	Health Center at Kiowa	320 Comanche Street	Kiowa	CO
CH081460	Active	BPS-H80-014303	PEAK VISTA COMMUNITY HEALTH CENTERS	Peak Vista Administrative Services Center	3205 N Academy Blvd Ste 130	Colorado Springs	CO
CH081460Y	Active	BPS-H80-010559	PEAK VISTA COMMUNITY HEALTH CENTERS	Pediatric Health Center at International Circle	2828 International Circle STE 140	Colorado Springs	CO
CH081460Z	Terminated	BPS-H80-010560	PEAK VISTA COMMUNITY HEALTH CENTERS	Moreno Health Center	875 W Moreno Ave	Colorado Springs	CO
CH08146AB	Terminated	BPS-H80-010599	PEAK VISTA COMMUNITY HEALTH CENTERS	Health Center at International Circle	2828 International Circle STE 160	Colorado Springs	CO
CH08146AC	Terminated	BPS-H80-008157	PEAK VISTA COMMUNITY HEALTH CENTERS	CRIPPLE CREEK VICTOR MOUNTAIN HEALTH CENTER	412 NORTH C STREET	CRIPPLE CREEK	CO
CH08146AD	Active	BPS-H80-009591	PEAK VISTA COMMUNITY HEALTH CENTERS	Dental Health Center	2828 International Circle STE 100	Colorado Springs	CO
CH08146AE	Active	BPS-H80-009521	PEAK VISTA COMMUNITY HEALTH CENTERS	Mobile Health Services Van 1	2510 E PLATTE PL	Colorado Springs	CO
CH08146AF	Terminated	BPS-H80-008227	PEAK VISTA COMMUNITY HEALTH CENTERS	RONALD MCDONALD CARE MOBILE	340 PRINTERS PARKWAY	COLORADO SPRINGS	CO
CH08146AG	Terminated	BPS-H80-012250	PEAK VISTA COMMUNITY HEALTH CENTERS	Falcon Peak School Based Health Center	12050 FALCON HWY	PEYTON	CO
CH08146AH	Active	BPS-H80-012545	PEAK VISTA COMMUNITY HEALTH CENTERS	Health Center at Academy, Suite 3500	3207 N Academy Blvd Ste 3500	Colorado Springs	CO
CH08146AJ	Active	BPS-H80-012709	PEAK VISTA COMMUNITY HEALTH CENTERS	Convenient Care Center	3205 N. Academy STE 100	Colorado Springs	CO
CH08146AK	Active	BPS-H80-012713	PEAK VISTA COMMUNITY HEALTH CENTERS	Health Center at Academy, Suite 3300	3207 N. Academy Boulevard STE 3300	Colorado Springs	CO
CH08146AL	Terminated	BPS-H80-012707	PEAK VISTA COMMUNITY HEALTH CENTERS	Health Center at Academy Suite 3100	3207 N Academy Blvd STE 3100	Colorado Springs	CO
CH08146AN	Active	BPS-H80-017084	PEAK VISTA COMMUNITY HEALTH CENTERS	Health Center at Printers Parkway, 340	340 Printers Parkway	Colorado Springs	CO
CH08146AP	Terminated	BPS-H80-017554	PEAK VISTA COMMUNITY HEALTH CENTERS	Health Center at South Circle	2864 South Circle Drive, Ste. 450	Colorado Springs	CO
CH08146AQ	Terminated	BPS-H80-018877	PEAK VISTA COMMUNITY HEALTH CENTERS	Health Center at Printer's Parkway, 155	155 Printer's Parkway Suite 230	Colorado Springs	CO
CH08146AR	Active	BPS-H80-027295	Peak Vista Community Health Centers	Health Center at Jet Wing	1815 Jet Wing Dr	Colorado Springs	CO
CH08146AS	Active	BPS-H80-029887	Peak Vista Community Health Centers	Family Health Center at Mitchell High School	4041 E San Miguel St	Colorado Springs	CO
CH08146AT	Terminated	BPS-H80-030617	Peak Vista Community Health Centers	Temporary Site - Colorado Springs City Auditorium	221 E Kiowa St	Colorado Springs	CO
CH08146AU	Terminated	BPS-H80-030616	Peak Vista Community Health Centers	Temporary Site - Springs Rescue Mission	5 W Las Vegas St	Colorado Springs	CO
CH08146AV	Active	BPS-H80-031017	Peak Vista Community Health Centers	Peak Vista Enrichment and Counseling Center	3207 N Academy Blvd Ste 100	Colorado Springs	CO
CH08146AW	Active	BPS-H80-031780	Peak Vista Community Health Centers	Springs Rescue Mission- Health Center	5 W Las Vegas St Rm 210	Colorado Springs	CO
CH08146AX	Active	BPS-H80-031779	Peak Vista Community Health Centers	Springs Rescue Mission- Health Center 2	5 W Las Vegas St Rm 211	Colorado Springs	CO
CH08146AY	Active	BPS-H80-034369	Peak Vista Community Health Centers	Downtown Health Center	111 E Las Vegas St	Colorado Springs	CO
CH08146AZ	Active	BPS-H80-036781	Peak Vista Community Health Centers	Developmental Disabilities Health Center	3205 N. Academy Blvd. STE 120	Colorado Springs	CO
CH08146BA	Terminated	BPS-H80-031018	PEAK VISTA COMMUNITY HEALTH CENTERS	The Place	423 E Cucharras St Ste 2	Colorado Springs	CO
CH08146C	Terminated	BPS-H80-009196	PEAK VISTA COMMUNITY HEALTH CENTERS	Health Center at Rio Grande	117 W Rio Grande St	Colorado Spgs	CO
CH08146D	Active	BPS-H80-001678	PEAK VISTA COMMUNITY HEALTH CENTERS	Health Center at Wahsatch, Enrichment & Counseling Center at Wahsatch	722 S Wahsatch Ave	Colorado Springs	CO
CH08146J	Terminated	BPS-H80-005383	PEAK VISTA COMMUNITY HEALTH CENTERS	Health Center at Printers Parkway, 350	350 Printers Pkwy	Colorado Springs	CO
CH08146R	Active	BPS-H80-013493	PEAK VISTA COMMUNITY HEALTH CENTERS	Lane Family Health Center	4863 N. Nevada	Colorado Springs	CO
CH08146S	Active	BPS-H80-005204	PEAK VISTA COMMUNITY HEALTH CENTERS	Health Center at Divide	34 Hybrook Rd S	Divide	CO
CH08146SA	Active	BPS-H80-001731	PEAK VISTA COMMUNITY HEALTH CENTERS	Health Center at Myron Stratton	410 Gold Pass Hts	Colorado Springs	CO
CH08146U	Terminated	BPS-H80-009590	PEAK VISTA COMMUNITY HEALTH CENTERS	Entrada School Based Health Center	1740 Pepperwood Dr	Colorado Spgs	CO
CH08146V	Active	BPS-H80-013439	PEAK VISTA COMMUNITY HEALTH CENTERS	Health Center at Fountain	350 Lyckman Dr	Fountain	CO
CH08146W	Active	BPS-H80-005239	PEAK VISTA COMMUNITY HEALTH CENTERS	Health Center at Union, Women's Health Center	225 S Union Blvd	Colorado Springs	CO
CH08146X	Active	BPS-H80-009523	PEAK VISTA COMMUNITY HEALTH CENTERS	Logan Health Center at Myron Stratton	430 Gold Pass Hts	Colorado Spgs	CO

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH080900	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	10/01/2023	07/03/2023
CH081460	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	10/01/2023
CH081460	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	10/01/2023
CH081460	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	10/01/2023
CH081460	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	10/01/2023	03/11/2024
CH081460	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	10/01/2023
CH081460	BEN'S FAMILY PHARMACY	DBA HONEST OAK LLC	333 M AVE STE 100	LIMON	CO	80828	04/01/2016	11/05/2023
CH081460	BENZER CO1 LLC	BYERS PHARMACY	568 US HIGHWAY 36	BYERS	CO	80103-9700	07/01/2017
CH08090C	BENZER CO1 LLC	BYERS PHARMACY	568 US HIGHWAY 36	BYERS	CO	80103-9700	01/01/2024
CH081460	CHASE PHARMACY	PRIMO ENTERPRISES INC.	568 U S HWY 36	BYERS	CO	80103-9700	10/01/2014	10/02/2017
CH081460	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	10/01/2022
CH081460	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	10/01/2022
CH081460	CVS PHARMACY, INC.	CVS/PHARMACY # 11002	455 NORTH CIRCLE DR	COLORADO SPRINGS	CO	80909	10/01/2020
CH081460	CVS PHARMACY, INC.	CVS PHARMACY # 16832	3810 BLOOMINGTON ST	COLORADO SPRINGS	CO	80922	10/01/2020
CH081460	CVS PHARMACY, INC.	CVS/PHARMACY # 11001	3475 N ACADEMY BLVD.	COLORADO SPRINGS	CO	80917	10/01/2020
CH081460	CVS PHARMACY, INC.	CVS PHARMACY # 16035	5240 N ACADEMY BLVD	COLORADO SPRINGS	CO	80918	10/01/2020
CH081460	CVS PHARMACY, INC.	CVS/PHARMACY # 11024	7353 RANGEWOOD DRIVE	COLORADO SPRINGS	CO	80918	10/01/2020
CH08146AR	CVS PHARMACY, INC.	CVS/PHARMACY # 11001	3475 N ACADEMY BLVD.	COLORADO SPRINGS	CO	80917	01/01/2024
CH08146SA	CVS PHARMACY, INC.	CVS PHARMACY # 16832	3810 BLOOMINGTON ST	COLORADO SPRINGS	CO	80922	01/01/2024
CH08146AN	CVS PHARMACY, INC.	CVS PHARMACY # 16035	5240 N ACADEMY BLVD	COLORADO SPRINGS	CO	80918	01/01/2024
CH081460Y	CVS PHARMACY, INC.	CVS/PHARMACY # 11002	455 NORTH CIRCLE DR	COLORADO SPRINGS	CO	80909	01/01/2024
CH08146AS	CVS PHARMACY, INC.	CVS/PHARMACY # 11024	7353 RANGEWOOD DRIVE	COLORADO SPRINGS	CO	80918	01/01/2024
CH081460	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	07/01/2022
CH081460	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	10/01/2023
CH081460	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	10/01/2023
CH081460	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	10/01/2023
CH081460	GENOA HEALTHCARE LLC	1795 JET WING DR RM 2230		COLORADO SPRINGS	CO	80916	10/01/2022
CH081460	GENOA HEALTHCARE LLC	875 W MORENO AVENUE		COLORADO SPRINGS	CO	80905	10/01/2022
CH081460	HOFFMAN DRUG	900 MAIN ST	BOX 609	LIMON	CO	80828	10/01/2014
CH080900	HOFFMAN DRUG	900 MAIN ST	BOX 609	LIMON	CO	80828	01/01/2024
CH081460	KING SOOPERS PHARMACY	DIV DILLON COMPANIES INC	1750 WEST UINTAH	COLORADO SPRINGS	CO	80904	10/01/2014
CH08146AK	KING SOOPERS PHARMACY	DIV DILLON COMPANIES INC	1750 WEST UINTAH	COLORADO SPRINGS	CO	80904	01/01/2024
CH081460	KING SOOPERS PHARMACY #103	2910 S ACADEMY BLVD		COLORADO SPRINGS	CO	80916	10/01/2014
CH08146AJ	KING SOOPERS PHARMACY #103	2910 S ACADEMY BLVD		COLORADO SPRINGS	CO	80916	01/01/2024
CH081460	KING SOOPERS PHARMACY #112	1045 FIRST ST.		BENNETT	CO	80102	01/01/2015
CH081460	KING SOOPERS PHARMACY #130	3620 AUSTIN BLUFFS PARKWAY		COLORADO SPRINGS	CO	80918	10/01/2014
CH08146AH	KING SOOPERS PHARMACY #130	3620 AUSTIN BLUFFS PARKWAY		COLORADO SPRINGS	CO	80918	01/01/2024
CH081460	KING SOOPERS PHARMACY #58	815 CHEYENNE MEADOWS ROAD		COLORADO SPRINGS	CO	80906	10/01/2014
CH08146AV	KING SOOPERS PHARMACY #58	815 CHEYENNE MEADOWS ROAD		COLORADO SPRINGS	CO	80906	01/01/2024
CH081460	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	10/01/2022
CH081460	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	10/01/2022
CH081460	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	10/01/2022
CH081460	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	10/01/2022
CH081460	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	10/01/2022
CH081460	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	07/01/2022	05/08/2024
CH081460	SAFEWAY INC	SAFEWAY PHARMACY #1532	220 ELIZABETH ST.	ELIZABETH	CO	80107-7562	10/01/2014	08/20/2015
CH081460	SAFEWAY INC	SAFEWAY PHARMACY #1644	7655 MCLAUGHLIN RD	FALCON	CO	80831	10/01/2014	08/20/2015
CH080900	SAFEWAY INC	SAFEWAY PHARMACY #1532	220 ELIZABETH ST.	ELIZABETH	CO	80107-7562	01/12/2012	07/31/2015
CH080900	SAFEWAY INC	SAFEWAY PHARMACY #1644	7655 MCLAUGHLIN RD	FALCON	CO	80831	01/12/2012	07/31/2015
CH081460	THE KROGER CO., KS 113	1220 S. LIPAN STREET		DENVER	CO	80223	10/01/2017
CH081460	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	10/01/2017
CH081460	WAL-MART PHARMACY 10-1200	3201 EAST PLATTE AVENUE		COLORADO SPRINGS	CO	80909	10/01/2014	08/20/2015
CH081460	WAL-MART PHARMACY 10-1200	3201 EAST PLATTE AVENUE		COLORADO SPRINGS	CO	80909	10/01/2017
CH08146AY	WAL-MART PHARMACY 10-1200	3201 EAST PLATTE AVENUE		COLORADO SPRINGS	CO	80909	01/01/2024
CH081460	WAL-MART PHARMACY 10-1273	6310 S. HWY 85-87		FOUNTAIN	CO	80817	10/01/2014	08/20/2015
CH081460	WAL-MART PHARMACY 10-1273	6310 S. HWY 85-87		FOUNTAIN	CO	80817	10/01/2017
CH08146V	WAL-MART PHARMACY 10-1273	6310 S. HWY 85-87		FOUNTAIN	CO	80817	01/01/2024
CH081460	WAL-MART PHARMACY 10-1434	707 SOUTH 8TH STREET		COLORDO SPRINGS (SW)	CO	80905	10/01/2014	08/20/2015
CH081460	WAL-MART PHARMACY 10-1434	707 SOUTH 8TH STREET		COLORDO SPRINGS (SW)	CO	80905	10/01/2017
CH08146D	WAL-MART PHARMACY 10-1434	707 SOUTH 8TH STREET		COLORDO SPRINGS (SW)	CO	80905	01/01/2024
CH081460	WAL-MART PHARMACY 10-3082	1622 SOUTH ACADEMY BLVD		COLORADO SPRINGS	CO	80916	10/01/2017
CH08146R	WAL-MART PHARMACY 10-3082	1622 SOUTH ACADEMY BLVD		COLORADO SPRINGS	CO	80916	01/01/2024
CH081460	WAL-MART PHARMACY 10-3083	665 N MURRAY BLVD		COLORADO SPRINGS	CO	80915-3405	10/01/2017
CH08146AZ	WAL-MART PHARMACY 10-3083	665 N MURRAY BLVD		COLORADO SPRINGS	CO	80915-3405	01/01/2024
CH081460	WAL-MART PHARMACY 10-3175	4142 AUSTIN BLUFFS PKWY		COLORADO SPRINGS	CO	80918	10/01/2017
CH081460	WAL-MART PHARMACY 10-3176	1725 N UNION BLVD		COLORADO SPRINGS	CO	80909-2850	10/01/2017
CH08146AE	WAL-MART PHARMACY 10-3176	1725 N UNION BLVD		COLORADO SPRINGS	CO	80909-2850	01/01/2024
CH081460	WAL-MART PHARMACY 10-3582	1575 SPACE CENTER DR		COLORADO SPRINGS	CO	80915	10/01/2014	08/20/2015
CH081460	WAL-MART PHARMACY 10-3582	1575 SPACE CENTER DR		COLORADO SPRINGS	CO	80915	10/01/2017
CH08146AW	WAL-MART PHARMACY 10-3582	1575 SPACE CENTER DR		COLORADO SPRINGS	CO	80915	01/01/2024
CH081460	WAL-MART PHARMACY 10-3805	19600 E US HIGHWAY 24		WOODLAND PARK	CO	80863	10/01/2017
CH08146S	WAL-MART PHARMACY 10-3805	19600 E US HIGHWAY 24		WOODLAND PARK	CO	80863	01/01/2024
CH081460	WAL-MART PHARMACY 10-4335	11550 MERIDIAN MARKET VIEW		FALCON	CO	80831	10/01/2017
CH08146AD	WAL-MART PHARMACY 10-4335	11550 MERIDIAN MARKET VIEW		FALCON	CO	80831	01/01/2024
CH081460	WAL-MART PHARMACY 10-5123	5550 EAST WOODMEN ROAD		COLORADO SPRINGS(NE)	CO	80920	10/01/2017
CH08146AX	WAL-MART PHARMACY 10-5123	5550 EAST WOODMEN ROAD		COLORADO SPRINGS(NE)	CO	80920	01/01/2024
CH081460	WAL-MART PHARMACY 10-5957	5957 WEST 44TH AVE		DENVER	CO	80212-7410	10/01/2017	03/22/2018
CH081460	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	10/01/2017
CH081460	WALGREEN ARIZONA DRUG CO		DBA WALGREENS 2400 N WALGREEN STREET	FLAGSTAFF	AZ	86004	08/03/2012	07/27/2015
CH081460	WALGREEN CO	DBA: WALGREENS #10057	4713 FLINTRIDGE DR	COLORADO SPRINGS	CO	80918	08/03/2012	04/29/2025
CH081460	WALGREEN CO	DBA WALGREENS SPECIALTY PHARMACY #11255	4545 E 9TH AVE STE 100	DENVER	CO	80220	08/03/2012
CH081460	WALGREEN CO	DBA: WALGREENS #11864	4315 CENTENNIAL BLVD	COLORADO SPRINGS	CO	80907	08/03/2012
CH081460	WALGREEN CO	DBA: WALGREENS	2370 E MAIN STREET	WOODLAND	CA	95776	08/03/2012	07/27/2015
CH081460	WALGREEN CO.	DBA: WALGREENS # 03583	2785 DUBLIN BLVD	COLORADO SPRINGS	CO	80918	08/03/2012
CH081460	WALGREEN CO.	DBA: WALGREENS # 03584	2921 N NEVADA	COLORADO SPRINGS	CO	80907	08/03/2012
CH081460	WALGREEN CO.	DBA: WALGREENS # 03585	6820 CENTENNIAL	COLORADO SPRINGS	CO	80919	08/03/2012
CH081460	WALGREEN CO.	DBA: WALGREENS # 03586	3480 N ACADEMY BLVD	COLORADO SPRINGS	CO	80917	08/03/2012
CH081460	WALGREEN CO.	DBA: WALGREENS # 03914	5755 CONSTITUTION AVE	COLORADO SPRINGS	CO	80915	08/03/2012
CH081460	WALGREEN CO.	DBA: WALGREENS # 04043	920 N. CIRCLE DR.	COLORADO SPRINGS	CO	80909	08/03/2012
CH081460	WALGREEN CO.	DBA: WALGREENS # 04596	1920 S. CHELTON ROAD	COLORADO SPRINGS	CO	80916	08/03/2012	04/24/2025
CH081460	WALGREEN CO.	DBA: WALGREENS # 04709	280 MAIN ST.	COLORADO SPRINGS	CO	80911	08/03/2012
CH081460	WALGREEN CO.	DBA: WALGREENS # 05262	8705 LEXINGTON DR	COLORADO SPRINGS	CO	80920	08/03/2012
CH081460	WALGREEN CO.	DBA: WALGREENS # 05547	350 N UNION	COLORADO SPRINGS	CO	80909	08/03/2012	04/28/2025
CH081460	WALGREEN CO.	DBA: WALGREENS # 05621	6011 RANGEWOOD DRIVE	COLORADO SPRINGS	CO	80918	08/03/2012
CH081460	WALGREEN CO.	DBA: WALGREENS # 05794	303 S CIRCLE DR	COLORADO SPRINGS	CO	80910	08/03/2012
CH081460	WALGREEN CO.	DBA: WALGREENS # 06731	4305 E PLATTE AVE	COLORADO SPRINGS	CO	80915-4104	08/03/2012	05/08/2024
CH081460	WALGREEN CO.	DBA: WALGREENS # 07022	7910 FOUNTAIN MESA RD	FOUNTAIN	CO	80817	08/03/2012
CH081460	WALGREEN CO.	DBA: WALGREENS # 07142	6075 BARNES ROAD	COLORADO SPRINGS	CO	80922	08/03/2012
CH081460	WALGREEN CO.	DBA: WALGREENS # 07777	625 N 19TH ST.	COLORADO SPRINGS	CO	80904	08/03/2012
CH081460	WALGREEN CO.	DBA: WALGREENS # 09199	7392 MCLAUGHLIN RD	FALCON	CO	80831	08/03/2012
CH081460	WALGREEN CO.	DBA: WALGREENS # 09561	140 PARADISE CIRCLE	WOODLAND PARK	CO	80863-9002	08/03/2012
CH081460	WALGREEN CO.	DBA: WALGREENS # 09767	1855 SOUTHGATE RD	COLORADO SPRINGS	CO	80906	08/03/2012
CH081460	WALGREEN CO.	DBA: WALGREENS # 09768	7390 RANGEWOOD DR	COLORADO SPRINGS	CO	80918	08/03/2012
CH081460	WALGREEN CO.	DBA: WALGREENS #11863	3143 W COLORADO AVENUE	COLORADO SPRINGS	CO	80904	08/03/2012	11/12/2024
CH081460	WALGREEN CO.	DBA: WALGREENS #12769	265 W HIGHWAY 105	MONUMENT	CO	80132	08/03/2012
CH081460	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16531	15 N UNION BLVD UNIT 120	COLORADO SPRINGS	CO	80909	10/01/2017
CH081460	Walgreens #21397	Walgreens Central Fill #21397	5675 Pecos St. Suite 100	Denver	CO	80221-6655	10/01/2022
CH081460	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	08/03/2012	07/27/2015
CH081460	WALGREENS MAIL SERVICE, INC.		8337 S PARK CIRCLE	ORLANDO	FL	32819-9049	07/01/2013	07/27/2015
CH081460	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	07/01/2022
CH081460	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/01/2022
CH081460	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	07/01/2022
CH081460	WALMART PHARMACY 10-3018	4425 VENETUCCI BLVD		FOUNTAIN	CO	80906	10/01/2017
CH08146X	WALMART PHARMACY 10-3018	4425 VENETUCCI BLVD		FOUNTAIN	CO	80906	01/01/2024
CH081460	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/01/2023
CH081460	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Boudreaux, Katie Pharmacy Director Peak Vista Community Health Centers 7193446269	Boudreaux, Katie Vice President of Pharmacy Services Peak Vista Community Health Centers 7193446269	1/24/2024 1:17 PM
Contacts	Authorizing Official	Update	Profile Change Request	Ramey, Lisa CMDO and Interim CEO PVCHC 7193446455	Ramey, Lisa CMDO PVCHC 7193446455	10/10/2022 11:03 AM
Details	State	Update		To Be Terminated	Terminated	7/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		10/1/2021 12:00:00 AM	6/21/2022 7:06 AM
Details	State	Update	Termination Request	Active	To Be Terminated	6/21/2022 7:06 AM
Terminations	Termination Date	Update	Termination Request		7/1/2022 12:00:00 AM	6/21/2022 7:06 AM
Terminations	Termination Effective Date	Update	Termination Request		6/14/2022 12:00:00 AM	6/21/2022 7:06 AM
Terminations	Termination Reason	Update	Termination Request		Site closure	6/21/2022 7:06 AM
Details	Last Recertification Date	Update	Recertification	2/10/2021 11:08:09 AM	2/1/2022 1:55:08 PM	2/1/2022 1:55 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	87034786 (CO)		12/16/2021 4:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1932437746 (CO)		12/16/2021 4:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/12/2021 3:03 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		87034786	10/12/2021 3:03 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	10/12/2021 3:03 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/12/2021 3:03 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9000143434	10/12/2021 3:03 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	10/12/2021 3:03 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1912240540	10/12/2021 3:03 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	10/12/2021 3:03 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1932437746	10/12/2021 3:03 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	10/12/2021 3:03 PM
Contacts	Authorizing Official	Update	Profile Change Request	Ramey, Lisa CMDO and Interim CEO PVCHC 7193446453	Ramey, Lisa CMDO and Interim CEO PVCHC 7193446455	9/17/2021 3:23 PM
Contacts	Primary Contact	Update	Group Change Request	Reilly, Paul Pharmacy Director Peak Vista Community Health Centers 7193446269	Boudreaux, Katie Pharmacy Director Peak Vista Community Health Centers 7193446269	7/7/2021 12:39 PM
Contacts	Authorizing Official	Update	AO Change Request	McManus, Pamela J. President and CEO Peak Vista CHC 7193446453	Ramey, Lisa CMDO and Interim CEO PVCHC 7193446453	4/7/2021 2:27 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1700834272 ( )		2/10/2021 11:08 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1205255304 ( )		2/10/2021 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1205255304	2/10/2021 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	2/10/2021 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700834272	2/10/2021 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	2/10/2021 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1730166034	2/10/2021 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	2/10/2021 11:08 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1730166034 ( )		2/10/2021 11:08 AM
Details	Last Recertification Date	Update	Recertification	1/28/2020 5:53:11 PM	2/10/2021 11:08:09 AM	2/10/2021 11:08 AM
Addresses	Main Address	Update	Change Request	320 Comanche Street Kiowa, CO 80177	320 Comanche Street Kiowa, CO 80117	6/29/2020 11:29 AM
Details	Last Recertification Date	Update	Recertification	2/8/2019 5:24:21 PM	1/28/2020 5:53:11 PM	1/28/2020 5:53 PM
Contacts	Authorizing Official	Update	Change Request	MCMANUS, PAMELA J. PRESIDENT AND CEO Peak Vista CHC 7193446450	McManus, Pamela J. President and CEO Peak Vista CHC 7193446453	2/13/2019 8:12 AM
Details	Last Recertification Date	Update	Recertification	2/16/2018 4:50:51 PM	2/8/2019 5:24:21 PM	2/8/2019 5:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/23/2018 2:53 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		05638267	5/23/2018 2:53 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	5/23/2018 2:53 PM
Details	Last Recertification Date	Update	Recertification	2/16/2017 12:00:00 AM	2/16/2018 4:50:51 PM	2/16/2018 4:50 PM
Contacts	Authorizing Official	Update		MCMANUS, PAMELA J. PRESIDENT AND CEO 7193446450	MCMANUS, PAMELA J. PRESIDENT AND CEO Peak Vista CHC 7193446450	10/11/2017 4:20 PM
Contacts	Primary Contact	Update		Reilly, Paul Pharmacy Director 7193446269	Reilly, Paul Pharmacy Director Peak Vista Community Health Centers 7193446269	9/22/2017 6:29 PM
Contacts	Authorizing Official	Insert			MCMANUS, PAMELA J. PRESIDENT AND CEO 7193446450	7/24/2017 12:19 PM
Contacts	Primary Contact	Insert			Reilly, Paul Pharmacy Director 7193446269	7/24/2017 12:19 PM
Addresses	Main Address	Insert			320 Comanche Street Kiowa, CO 80177	7/12/2017 9:43 AM
Contacts	Signed By	Insert			Honea, Morgan CEO 7197751095	7/12/2017 9:43 AM
Addresses	Billing Address	Insert			PEAK VISTA COMMUNITY HEALTH CENTERS 3205 N. Academy Blvd, Suite 130 Colorado Springs, CO 80917	3/8/2017 12:05 PM
Addresses	Shipping Address	Insert			Peak Vista CHC Pharmacy 225 S. Union Blvd Colorado Springs, CO 80910	3/8/2017 12:05 PM
Details	Last Recertification Date	Update		2/26/2016 12:00:00 AM	2/16/2017 12:00:00 AM	2/16/2017 4:31 PM
Medicaid Billing	NPI: Number	Insert			1730166034	10/11/2016 10:29 AM
Details	Last Recertification Date	Update		2/11/2015 12:00:00 AM	2/26/2016 12:00:00 AM	2/26/2016 1:40 PM
Details	Last Recertification Date	Update		2/10/2014 12:00:00 AM	2/11/2015 12:00:00 AM	2/11/2015 12:00 PM
Details	Entity Subname	Update		Peak Vista Health Center at Kiowa	Health Center at Kiowa	1/12/2015 5:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/11/2015 10:37 PM
Medicaid Billing	Medicaid: Number	Insert			67134866	1/11/2015 10:37 PM
Medicaid Billing	Medicaid: State	Insert			CO	1/11/2015 10:37 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/14/2014 2:02 PM
Medicaid Billing	Medicaid: Number	Insert			03000221	10/14/2014 2:02 PM
Medicaid Billing	Medicaid: State	Insert			CO	10/14/2014 2:02 PM
Medicaid Billing	NPI: Number	Insert			1700834272	10/14/2014 2:02 PM
Medicaid Billing	NPI: Number	Insert			1205255304	10/14/2014 2:02 PM
Details	Entity Subname	Update		Kiowa Clinic	Peak Vista Health Center at Kiowa	8/14/2014 12:01 PM
Details	Comments Public	Insert			8/7/14 PLAINS MEDICAL CENTER merged with PEAK VISTA COMMUNITY HEALTH CENTERS, 340B IDs remain the same but organization name, EIN, grant number, AO and billing organization have changed	8/7/2014 11:57 AM
Details	Grant Number	Update		H80CS00882	H80CS00212	8/7/2014 11:33 AM
Details	Entity Name	Update		PLAINS MEDICAL CENTER	PEAK VISTA COMMUNITY HEALTH CENTERS	8/7/2014 11:33 AM
Details	Entity Name	Update		Plains Medical Center	PLAINS MEDICAL CENTER	3/31/2014 4:25 PM
Details	Last Recertification Date	Update		4/1/2013 12:00:00 AM	2/10/2014 12:00:00 AM	2/10/2014 10:33 AM
Details	Last Recertification Date	Update			4/1/2013 12:00:00 AM	3/13/2013 8:46 AM
Details	340B ID	Update		IS-FF-CH08090D	CH08090D	11/16/2012 5:50 PM
Dates	Participating Approval Date	Update			11/16/2012 12:00:00 AM	11/16/2012 5:50 PM
Details	State	Update		Pending	Active	11/16/2012 5:50 PM
Dates	Start Date	Update			1/1/2013 12:00:00 AM	11/16/2012 5:50 PM
Details	340B ID	Update		ONLINE_REG	IS-FF-CH08090D	11/14/2012 1:25 PM
Details	Last Recertification Date	Insert				9/18/2012 12:38 PM
Details	Grant Number	Insert			H80CS00882	9/18/2012 12:38 PM
Details	340B ID	Insert			ONLINE_REG	9/18/2012 12:38 PM
Details	Is Authorizing Official EHB Data	Insert				9/18/2012 12:38 PM
Dates	Last Date That 340B Drugs Purchased	Insert				9/18/2012 12:38 PM
Details	Medicare Provider Number	Insert				9/18/2012 12:38 PM
Details	Entity Name	Insert			Plains Medical Center	9/18/2012 12:38 PM
Details	Program Code	Insert			CH	9/18/2012 12:38 PM
Details	Entity Subname	Insert			Kiowa Clinic	9/18/2012 12:38 PM
Dates	Participating Approval Date	Insert				9/18/2012 12:38 PM
Details	State	Insert			Pending	9/18/2012 12:38 PM
Dates	Registration Date	Insert			9/18/2012 12:00:00 AM	9/18/2012 12:38 PM
Dates	Signed By Date	Insert			9/18/2012 12:00:00 AM	9/18/2012 12:38 PM
Dates	Start Date	Insert				9/18/2012 12:38 PM
Terminations	Termination Comments	Insert				9/18/2012 12:38 PM
Terminations	Termination Date	Insert				9/18/2012 12:38 PM
Terminations	Termination Effective Date	Insert				9/18/2012 12:38 PM
Terminations	Termination Reason	Insert				9/18/2012 12:38 PM

340B Drug Pricing Program Database