Covered Entity Details

FQHCLA225W Maricopa County Special Health Care District (Terminated) - information as of 6/27/2025 12:31:10 AM

Main Details

Name

Maricopa County Special Health Care District

Subdivision Name

SOUTH CENTRAL FHC CLINIC 100501009

Type

Health Center Program Look-Alike

Site ID

BPS-LAL-011991

340B ID

FQHCLA225W

Grant Number

LALCS00037

Additional Details

Current Program Status

Terminated

Registration Date

1/9/2013

Participating Start Date

4/1/2013

Participating Approval Date

2/27/2013

Last Recertification Date

2/8/2018

Termination Date
Termination Reason

7/1/2018
Site closure

Contacts

Authorizing Official

Maricopa Integrated Health Center
Kris Gaw, Chief Operating Officer
(602) 344-1258

Primary Contact

Maricopa Integrated Health System
Donald L Holladay, Assistant Director of Pharmacy
(602) 344-8565

Addresses

Street Address

1616 E. Roeser Road
Phoenix, AZ 85040

Billing Address

Maricopa Medical Center
2601 E. Roosevelt
Phoenix, AZ 85008

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
AZ	946617
		1619396462

Shipping Addresses

Shipping Address 1

South Central FHC Pharmacy
33 W. Tamarisk
Phoenix, AZ 85041

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	AVELLA OF DEER VALLEY	23620 N 20TH DR #12	PHOENIX	AZ	85085-0621	07/16/2016	10/01/2016	07/01/2018	07/01/2018
Contract Detail	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102	PHOENIX	AZ	85004	07/16/2016	10/01/2016	07/01/2018	07/01/2018
Contract Detail	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102	SCOTTSDALE	AZ	85258	07/16/2016	10/01/2016	07/01/2018	07/01/2018

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	Address Cont.	City	State
FQHCLA225	Terminated	Admin	Maricopa County Special Health Care District		2601 E. ROOSEVELT STREET		PHOENIX	AZ
FQHCLA225A	Terminated	BPS-LAL-009882	Maricopa County Special Health Care District	CHANDLER FAMILY HEALTH CENTER	811 S. HAMILTON		CHANDLER	AZ
FQHCLA225B	Terminated	BPS-LAL-009890	Maricopa County Special Health Care District	GLENDALE FAMILY HEALTH CENTER	5141 W. LAMAR		GLENDALE	AZ
FQHCLA225C	Terminated	BPS-LAL-009884	Maricopa County Special Health Care District	MESA FAMILY HEALTH CENTER	59 S HIBBERT		MESA	AZ
FQHCLA225D	Terminated	BPS-LAL-009889	Maricopa County Special Health Care District	7TH AVENUE FAMILY HEALTH CENTER	1205 S 7TH AVENUE		PHOENIX	AZ
FQHCLA225E	Terminated	BPS-LAL-009883	Maricopa County Special Health Care District	SOUTH CENTRAL FAMILY HEALTH CENTER	33 W. TAMARISK		PHOENIX	AZ
FQHCLA225F	Terminated	BPS-LAL-009887	Maricopa County Special Health Care District	SUNNYSLOPE FAMILY HEALTH CENTER	934 W. HATCHER		PHOENIX	AZ
FQHCLA225G	Terminated	BPS-LAL-009881	Maricopa County Special Health Care District	AVONDALE FAMILY HEALTH CENTER	950 E. VAN BUREN		AVONDALE	AZ
FQHCLA225H	Terminated	BPS-LAL-009891	Maricopa County Special Health Care District	Comprehensive Health Center	2525 E. Roosevelt Street		Phoenix	AZ
FQHCLA225J	Terminated	BPS-LAL-009885	Maricopa County Special Health Care District	7th Avenue Walk In Clinic	1201 S. 7th Avenue		Phoenix	AZ
FQHCLA225K	Terminated	BPS-LAL-009886	Maricopa County Special Health Care District	El Mirage Family Health Center	12428 W. Thunderbird Road		El MIrage	AZ
FQHCLA225L	Terminated	BPS-LAL-009893	Maricopa County Special Health Care District	Guadalupe Family Health Center	5825 E. Calle Guadalupe		Guadalupe	AZ
FQHCLA225M	Terminated	BPS-LAL-009892	Maricopa County Special Health Care District	Maryvale Family Health Center	4011 N. 51st Ave.		Phoenix	AZ
FQHCLA225N	Terminated	BPS-LAL-013860	Maricopa County Special Health Care District	McDowell Healthcare Center	1101 N Central Ave		Phoenix	AZ
FQHCLA225P	Terminated	BPS-LAL-012143	Maricopa County Special Health Care District	Whole Health Home Clinic Choices Midtown	3333 N. 7th Avenue		Phoenix	AZ
FQHCLA225Q	Terminated	BPS-LAL-011993	Maricopa County Special Health Care District	Whole Health Home Clinic POCN Comunidad	1035 E. Jefferson Street	STE B	Phoenix	AZ
FQHCLA225R	Terminated	BPS-LAL-011992	Maricopa County Special Health Care District	Whole Health Home Clinic SWN San Tan	1465 W. Chandler Blvd BLDG A		Chandler	AZ
FQHCLA225S	Terminated	BPS-LAL-012127	Maricopa County Special Health Care District	Whole Health Home Clinic SWN Highland	4707 N. 12th St.		Phoenix	AZ
FQHCLA225T	Terminated	BPS-LAL-012126	Maricopa County Special Health Care District	Whole Health Home Clinic PIR East Valley	4330 E. University Drive		Mesa	AZ
FQHCLA225U	Terminated	BPS-LAL-011990	MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT	Whole Health Home Clinic PIR Metro	10240 N 31st Avenue	STE 200B	Phoenix	AZ
FQHCLA225V	Terminated	BPS-LAL-012128	Maricopa County Special Health Care District	7TH STREET Home Clinic POCN Capitol 100508009	1540 W. Van Buren Street		Phoenix	AZ
FQHCLA225W	Terminated	BPS-LAL-011991	Maricopa County Special Health Care District	SOUTH CENTRAL FHC CLINIC 100501009	1616 E. Roeser Road		Phoenix	AZ
FQHCLA225X	Terminated	BPS-LAL-014639	Maricopa County Special Health Care District	Pendergast Family Health Center	10550 W Mariposa Street		Phoenix	AZ

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
FQHCLA225	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	01/01/2018	04/01/2020
FQHCLA225	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	01/01/2018	04/01/2020
FQHCLA225A	ALBERTSON'S LLC	OSCO DRUG #2952	8035 NORTH 19TH AVE	PHOENIX	AZ	85021	07/01/2017	04/01/2020
FQHCLA225A	ALBERTSON'S LLC	OSCO DRUG #980	1951 W BASELINE	MESA	AZ	85202	07/01/2017	04/01/2020
FQHCLA225	ALBERTSON'S LLC	OSCO DRUG #2952	8035 NORTH 19TH AVE	PHOENIX	AZ	85021	07/01/2017	04/01/2020
FQHCLA225	ALBERTSON'S LLC	OSCO DRUG #980	1951 W BASELINE	MESA	AZ	85202	07/01/2017	04/01/2020
FQHCLA225A	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 08914	50 W. JEFFERSON ST., SUITE 140	PHOENIX	AZ	85003	07/01/2017	04/01/2020
FQHCLA225A	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09225	2406 EAST THOMAS RD.	PHOENIX	AZ	85016	07/01/2017	04/01/2020
FQHCLA225A	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09327	6021 S CENTRAL AVE	PHOENIX	AZ	85042	07/01/2017	04/01/2020
FQHCLA225	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 08914	50 W. JEFFERSON ST., SUITE 140	PHOENIX	AZ	85003	07/01/2017	04/01/2020
FQHCLA225	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09225	2406 EAST THOMAS RD.	PHOENIX	AZ	85016	07/01/2017	04/01/2020
FQHCLA225	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09327	6021 S CENTRAL AVE	PHOENIX	AZ	85042	07/01/2017	04/01/2020
FQHCLA225	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03383	7550 SOUTH 19TH AVE.	PHOENIX	AZ	85041	01/01/2019	04/01/2020
FQHCLA225	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09314	3440 WEST GLENDALE AVE	PHOENIX	AZ	85051	01/01/2019	04/01/2020
FQHCLA225	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09347	1525 NORTH CENTRAL AVENUE	PHOENIX	AZ	85004	01/01/2019	04/01/2020
FQHCLA225	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09304	7434 W INDIAN SCHOOL RD	PHOENIX	AZ	85033	01/01/2019	04/01/2020
FQHCLA225	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09218	1137 S. DOBSON RD #10	MESA	AZ	85202	01/01/2019	04/01/2020
FQHCLA225	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09256	3560 WEST PEORIA AVENUE	PHOENIX	AZ	85029	01/01/2019	04/01/2020
FQHCLA225	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09293	325 W APACHE TRAIL	APACHE JUNCTION	AZ	85120	01/01/2019	04/01/2020
FQHCLA225	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09213	305 E. BROWN RD.	MESA	AZ	85201	01/01/2019	04/01/2020
FQHCLA225	ARIZONA CVS STORES, L.L.C.	DBA CVS/PHARMACY # 8983	5125 W. OLIVE AVE	GLENDALE	AZ	85302	01/01/2019	04/01/2020
FQHCLA225G	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	04/01/2020
FQHCLA225A	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	04/01/2020
FQHCLA225B	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	04/01/2020
FQHCLA225C	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	04/01/2020
FQHCLA225D	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	04/01/2020
FQHCLA225E	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	04/01/2020
FQHCLA225F	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	04/01/2020
FQHCLA225	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	04/01/2020
FQHCLA225H	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	04/01/2020
FQHCLA225K	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	04/01/2020
FQHCLA225L	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	04/01/2020
FQHCLA225M	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	04/01/2020
FQHCLA225N	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	04/01/2020
FQHCLA225J	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	10/01/2019
FQHCLA225V	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	07/01/2018
FQHCLA225W	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	07/01/2018
FQHCLA225P	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	07/01/2018
FQHCLA225Q	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	04/01/2019
FQHCLA225R	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	10/01/2018
FQHCLA225S	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	10/01/2018
FQHCLA225T	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	07/01/2018
FQHCLA225U	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	07/01/2018
FQHCLA225X	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/01/2016	10/01/2018
FQHCLA225A	AVELLA OF DEER VALLEY, INC. #38	DBA AVELLA SPECIALTY PHARMACY	24416 N. 19TH AVE	PHOENIX	AZ	85085	10/01/2017	04/01/2020
FQHCLA225	AVELLA OF DEER VALLEY, INC. #38	DBA AVELLA SPECIALTY PHARMACY	24416 N. 19TH AVE	PHOENIX	AZ	85085	04/01/2017	04/01/2020
FQHCLA225	AVELLA OF DEER VALLEY, INC. #38	24416 N. 19TH AVE		PHOENIX	AZ	85085-1887	01/01/2018	04/01/2020
FQHCLA225G	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	04/01/2020
FQHCLA225A	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	04/01/2020
FQHCLA225B	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	04/01/2020
FQHCLA225C	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	04/01/2020
FQHCLA225D	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	04/01/2020
FQHCLA225E	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	04/01/2020
FQHCLA225F	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	04/01/2020
FQHCLA225	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	04/01/2020
FQHCLA225H	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	04/01/2020
FQHCLA225K	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	04/01/2020
FQHCLA225L	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	04/01/2020
FQHCLA225M	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	04/01/2020
FQHCLA225N	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	04/01/2020
FQHCLA225J	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	10/01/2019
FQHCLA225V	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	07/01/2018
FQHCLA225W	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	07/01/2018
FQHCLA225P	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	07/01/2018
FQHCLA225Q	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	04/01/2019
FQHCLA225R	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	10/01/2018
FQHCLA225S	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	10/01/2018
FQHCLA225T	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	07/01/2018
FQHCLA225U	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	07/01/2018
FQHCLA225X	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/01/2016	10/01/2018
FQHCLA225	AVELLA OF SACRAMENTO, INC.	2288 AUBURN BLVD #102		SACRAMENTO	CA	95821	04/01/2018	04/01/2020
FQHCLA225G	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	04/01/2020
FQHCLA225A	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	04/01/2020
FQHCLA225B	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	04/01/2020
FQHCLA225C	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	04/01/2020
FQHCLA225D	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	04/01/2020
FQHCLA225E	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	04/01/2020
FQHCLA225F	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	04/01/2020
FQHCLA225	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	04/01/2020
FQHCLA225H	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	04/01/2020
FQHCLA225K	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	04/01/2020
FQHCLA225L	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	04/01/2020
FQHCLA225M	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	04/01/2020
FQHCLA225N	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	04/01/2020
FQHCLA225J	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	10/01/2019
FQHCLA225V	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	07/01/2018
FQHCLA225W	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	07/01/2018
FQHCLA225P	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	07/01/2018
FQHCLA225Q	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	04/01/2019
FQHCLA225R	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	10/01/2018
FQHCLA225S	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	10/01/2018
FQHCLA225T	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	07/01/2018
FQHCLA225U	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	07/01/2018
FQHCLA225X	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/01/2016	10/01/2018
FQHCLA225	BRIOVARX OF MAINE INC	DBA BRIOVARX	53 DARLING AVE	SOUTH PORTLAND	ME	04106	01/01/2018	04/01/2020
FQHCLA225	BRIOVARX OF MASSACHUSETTS, LLC	D/B/A BRIOVARX	BLDG 2 - UNIT A 145 BODWELL STREET	AVON	MA	02322	01/01/2018	04/01/2020
FQHCLA225	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	01/01/2018	04/01/2020
FQHCLA225	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	01/01/2018	04/01/2020
FQHCLA225	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	01/01/2018	04/01/2020
FQHCLA225	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	01/01/2018	04/01/2020
FQHCLA225	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	01/01/2018	04/01/2020
FQHCLA225	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	01/01/2018	04/01/2020
FQHCLA225	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	01/01/2018	04/01/2020
FQHCLA225	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	01/01/2018	04/01/2020
FQHCLA225	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	01/01/2018	04/01/2020
FQHCLA225A	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05778	4040 N. 19TH AVE.	PHOENIX	AZ	85015	07/01/2017	04/01/2020
FQHCLA225A	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 09222	4275 W. THOMAS RD.	PHOENIX	AZ	85019	07/01/2017	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05778	4040 N. 19TH AVE.	PHOENIX	AZ	85015	07/01/2017	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 09222	4275 W. THOMAS RD.	PHOENIX	AZ	85019	07/01/2017	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 03500	1625 N. 44TH ST.	PHOENIX	AZ	85008	01/01/2019	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 07860	1615 E. BASELINE RD.	PHOENIX	AZ	85042	01/01/2019	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 08366	1610 E CAMELBACK RD	PHOENIX	AZ	85016	01/01/2019	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 00040	1424 W BASELINE RD	TEMPE	AZ	85283	01/01/2019	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 06718	5835 W. INDIAN SCHOOL RD.	PHOENIX	AZ	85031	01/01/2019	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05849	990 E. PECOS RD.	CHANDLER	AZ	85225	01/01/2019	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05892	5050 W. BASELINE RD.	LAVEEN	AZ	85339	01/01/2019	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 06862	1850 W. DUNLAP AVE.	PHOENIX	AZ	85021	01/01/2019	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 07872	7499 W. BETHANY HOME RD.	GLENDALE	AZ	85303	01/01/2019	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	CVS/PHARMACY # 2963	711 E. INDIAN SCHOOL RD.	PHOENIX	AZ	85014	01/01/2019	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 00033	1750 E BROADWAY RD	TEMPE	AZ	85282	01/01/2019	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 07849	1015 E. RAY RD.	CHANDLER	AZ	85225	01/01/2019	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	CVS PHARMACY # 17024	2140 E BASELINE RD	PHOENIX	AZ	85042	01/01/2019	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05315	2005 N. DOBSON RD.	CHANDLER	AZ	85224	01/01/2019	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 01759	10 E DUNLAP AVE	PHOENIX	AZ	85020	01/01/2019	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 01743	13870 W. GREENWAY RD.	SURPRISE	AZ	85374	01/01/2019	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 09205	802 S. MILL AVE.	TEMPE	AZ	85281	01/01/2019	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	DBA CVS/PHARMACY #10229	280 N. AVONDALE BLVD	AVONDALE	AZ	85323	01/01/2019	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 07262	18460 N. 7TH ST.	PHOENIX	AZ	85022	01/01/2019	04/01/2020
FQHCLA225	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 07845	7552 E. INDIAN SCHOOL RD.	SCOTTSDALE	AZ	85251	01/01/2019	04/01/2020
FQHCLA225	GOODYEAR CVS, L.L.C.	DBA: CVS/PHARMACY # 03749	2840 N. DYSART RD.	GOODYEAR	AZ	85395	01/01/2019	04/01/2020
FQHCLA225	ONCOMED PHARMACEUTICAL SERVICES OF MA, L	D/B/A ONCO360	335 BEAR HILL RD STE 2100	WALTHAM	MA	02451	01/01/2018	04/01/2020
FQHCLA225	ONCOMED THE ONCOLOGY PHARMACY OF BUFFALO	D/B/A ONCO360	140 JOHN JAMES AUDUBON PKWY STE 101	AMHERST	NY	14228	01/01/2018	04/01/2020
FQHCLA225	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	01/01/2018	04/01/2020
FQHCLA225	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	01/01/2018	04/01/2020
FQHCLA225	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	01/01/2018	04/01/2020
FQHCLA225	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	01/01/2018	04/01/2020
FQHCLA225	OPTUM PHARMACY 800, INC.	3016 GUADALUPE ST STE A		AUSTIN	TX	78705-2861	04/01/2018	04/01/2020
FQHCLA225	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	01/01/2018	04/01/2020
FQHCLA225	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #3129	1002 EAST MCDOWELL ROAD	PHOENIX	AZ	85006	01/01/2018	04/01/2020
FQHCLA225A	SAFEWAY INC	SAFEWAY PHARMACY #1591	6202 S. 16TH STREET	PHOENIX	AZ	85040	07/01/2017	04/01/2020
FQHCLA225A	SAFEWAY INC	SAFEWAY PHARMACY #1662	10641 W. OLIVE AVENUE	PEORIA	AZ	85345	07/01/2017	04/01/2020
FQHCLA225A	SAFEWAY INC	SAFEWAY PHARMACY #2651	340 E. MCDOWELL ROAD	PHOENIX	AZ	85004	07/01/2017	04/01/2020
FQHCLA225A	SAFEWAY INC	SAFEWAY PHARMACY #1536	401 EAST HIGHWAY260	PAYSON	AZ	85541	07/01/2017	04/12/2017
FQHCLA225A	SAFEWAY INC	SAFEWAY PHARMACY #0174	520 WEST OSBORN ROAD	PHOENIX	AZ	85013	07/01/2017	04/01/2020
FQHCLA225A	SAFEWAY INC	SAFEWAY PHARMACY #1202	3131 E THUNDERBIRD ROAD	PHOENIX	AZ	85032	07/01/2017	04/01/2020
FQHCLA225A	SAFEWAY INC	SAFEWAY PHARMACY #0257	8021 N. 35TH AVENUE	PHOENIX	AZ	85051	07/01/2017	04/01/2020
FQHCLA225A	SAFEWAY INC	SAFEWAY PHARMACY #2042	3132 E CAMELBACK RD	PHOENIX	AZ	85016	07/01/2017	04/01/2020
FQHCLA225A	SAFEWAY INC	SAFEWAY PHARMACY #1584	1999 W WICKENBURG WAY	WICKENBURG	AZ	85390	07/01/2017	04/12/2017
FQHCLA225A	SAFEWAY INC	SAFEWAY PHARMACY #1604	1159 W. CHANDLER BLVD.	CHANDLER	AZ	85224	07/01/2017	04/01/2020
FQHCLA225A	SAFEWAY INC	SAFEWAY PHARMACY #1515	810 E. GLENDALE AVENUE	PHOENIX	AZ	85020	07/01/2017	04/01/2020
FQHCLA225A	SAFEWAY INC	SAFEWAY PHARMACY #2821	3800 WEST HAPPY VALLEY ROAD	GLENDALE	AZ	85310	07/01/2017	04/12/2017
FQHCLA225A	SAFEWAY INC	SAFEWAY PHARMACY #1717	1960 WEST MAIN STREET	MESA	AZ	85201	07/01/2017	04/01/2020
FQHCLA225A	SAFEWAY INC	SAFEWAY PHARMACY #0955	2600 WILLOW PASS ROAD	CONCORD	CA	94519	07/01/2017	04/01/2020
FQHCLA225	SAFEWAY INC	SAFEWAY PHARMACY #1591	6202 S. 16TH STREET	PHOENIX	AZ	85040	07/01/2017	04/01/2020
FQHCLA225	SAFEWAY INC	SAFEWAY PHARMACY #1662	10641 W. OLIVE AVENUE	PEORIA	AZ	85345	07/01/2017	04/01/2020
FQHCLA225	SAFEWAY INC	SAFEWAY PHARMACY #2651	340 E. MCDOWELL ROAD	PHOENIX	AZ	85004	07/01/2017	04/01/2020
FQHCLA225	SAFEWAY INC	SAFEWAY PHARMACY #1536	401 EAST HIGHWAY260	PAYSON	AZ	85541	07/01/2017	04/12/2017
FQHCLA225	SAFEWAY INC	SAFEWAY PHARMACY #0174	520 WEST OSBORN ROAD	PHOENIX	AZ	85013	07/01/2017	04/01/2020
FQHCLA225	SAFEWAY INC	SAFEWAY PHARMACY #1202	3131 E THUNDERBIRD ROAD	PHOENIX	AZ	85032	07/01/2017	04/01/2020
FQHCLA225	SAFEWAY INC	SAFEWAY PHARMACY #0257	8021 N. 35TH AVENUE	PHOENIX	AZ	85051	07/01/2017	07/10/2018
FQHCLA225	SAFEWAY INC	SAFEWAY PHARMACY #2042	3132 E CAMELBACK RD	PHOENIX	AZ	85016	07/01/2017	04/01/2020
FQHCLA225	SAFEWAY INC	SAFEWAY PHARMACY #1584	1999 W WICKENBURG WAY	WICKENBURG	AZ	85390	07/01/2017	04/12/2017
FQHCLA225	SAFEWAY INC	SAFEWAY PHARMACY #1604	1159 W. CHANDLER BLVD.	CHANDLER	AZ	85224	07/01/2017	04/01/2020
FQHCLA225	SAFEWAY INC	SAFEWAY PHARMACY #1515	810 E. GLENDALE AVENUE	PHOENIX	AZ	85020	07/01/2017	04/01/2020
FQHCLA225	SAFEWAY INC	SAFEWAY PHARMACY #2821	3800 WEST HAPPY VALLEY ROAD	GLENDALE	AZ	85310	07/01/2017	04/01/2020
FQHCLA225	SAFEWAY INC	SAFEWAY PHARMACY #1717	1960 WEST MAIN STREET	MESA	AZ	85201	07/01/2017	04/12/2017
FQHCLA225	SAFEWAY INC	SAFEWAY PHARMACY #0955	2600 WILLOW PASS ROAD	CONCORD	CA	94519	07/01/2017	10/01/2017
FQHCLA225K	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	01/01/2018	04/01/2020
FQHCLA225	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	01/01/2018	04/01/2020
FQHCLA225	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	01/01/2018	04/01/2020
FQHCLA225A	SMITH'S FOOD & DRUG	DBA FRY'S FOOD AND DRUG #113	1245 W MAIN STREET	MESA	AZ	85201	07/01/2017	04/01/2020
FQHCLA225	SMITH'S FOOD & DRUG	DBA FRY'S FOOD AND DRUG #113	1245 W MAIN STREET	MESA	AZ	85201	07/01/2017	04/01/2020
FQHCLA225A	SMITH'S FOOD & DRUG CENTER	DBA FRY'S FOOD AND DRUG #135	4505 E THOMAS ROAD	PHOENIX	AZ	85018	07/01/2017	04/01/2020
FQHCLA225	SMITH'S FOOD & DRUG CENTER	DBA FRY'S FOOD AND DRUG #135	4505 E THOMAS ROAD	PHOENIX	AZ	85018	07/01/2017	04/01/2020
FQHCLA225A	SMITH'S FOOD & DRUG CENTERS, INC.	FRY'S PHARMACY #112	1575 N DYSART ROAD	AVONDALE	AZ	85392	07/01/2017	04/01/2020
FQHCLA225	SMITH'S FOOD & DRUG CENTERS, INC.	FRY'S PHARMACY #112	1575 N DYSART ROAD	AVONDALE	AZ	85392	07/01/2017	04/01/2020
FQHCLA225A	SMITH'S FOOD & DRUG CTRS	DBA FRY'S FOOD STORES #89	11425 W BUCKEYE RD	AVONDALE	AZ	85323	07/01/2017	04/01/2020
FQHCLA225A	SMITH'S FOOD & DRUG CTRS	DBA FRY'S FOOD AND DRUG #126	6601 W. INDIAN SCHOOL RD.	PHOENIX	AZ	85033	07/01/2017	04/01/2020
FQHCLA225	SMITH'S FOOD & DRUG CTRS	DBA FRY'S FOOD STORES #89	11425 W BUCKEYE RD	AVONDALE	AZ	85323	07/01/2017	04/01/2020
FQHCLA225	SMITH'S FOOD & DRUG CTRS	DBA FRY'S FOOD AND DRUG #126	6601 W. INDIAN SCHOOL RD.	PHOENIX	AZ	85033	07/01/2017	04/01/2020
FQHCLA225A	SMITH'S FOOD DRUG CENTERS	DBA FRYS FOOD AND DRUG #675	1300 S WATSON ROAD	BUCKEYE	AZ	85326	07/01/2017	04/01/2020
FQHCLA225	SMITH'S FOOD DRUG CENTERS	DBA FRYS FOOD AND DRUG #675	1300 S WATSON ROAD	BUCKEYE	AZ	85326	07/01/2017	04/01/2020
FQHCLA225A	SMITHS FOOD & DRUG CENTERS	DBA FRYS FOOD & DRUG #46	520 E BASELINE ROAD	PHOENIX	AZ	85040	07/01/2017	04/01/2020
FQHCLA225A	SMITHS FOOD & DRUG CENTERS	FRY'S PHARMACY #002	3036 E THOMAS RD	PHOENIX	AZ	85016	07/01/2017	04/01/2020
FQHCLA225A	SMITHS FOOD & DRUG CENTERS	DBA FRY'S FOOD & DRUG #610	4230 W. MCDOWELL ROAD	PHOENIX	AZ	85009	07/01/2017	04/01/2020
FQHCLA225A	SMITHS FOOD & DRUG CENTERS	DBA FRYS FOOD & DRUG #5	7770 E MCDOWELL	SCOTTSDALE	AZ	85257	07/01/2017	04/01/2020
FQHCLA225A	SMITHS FOOD & DRUG CENTERS	DBA FRYS FOOD & DRUG #10	4353 W BETHANY HOME ROAD	GLENDALE	AZ	85301	07/01/2017	04/01/2020
FQHCLA225A	SMITHS FOOD & DRUG CENTERS	DBA FRYS FOOD & DRUG #623	1815 W. GLENDALE AVENUE	PHOENIX	AZ	85021	07/01/2017	04/01/2020
FQHCLA225A	SMITHS FOOD & DRUG CENTERS	DBA FRYS FOOD & DRUG #129	4724 N. 20TH STREET	PHOENIX	AZ	85016	07/01/2017	04/01/2020
FQHCLA225	SMITHS FOOD & DRUG CENTERS	DBA FRYS FOOD & DRUG #46	520 E BASELINE ROAD	PHOENIX	AZ	85040	07/01/2017	04/01/2020
FQHCLA225	SMITHS FOOD & DRUG CENTERS	FRY'S PHARMACY #002	3036 E THOMAS RD	PHOENIX	AZ	85016	07/01/2017	04/01/2020
FQHCLA225	SMITHS FOOD & DRUG CENTERS	DBA FRY'S FOOD & DRUG #610	4230 W. MCDOWELL ROAD	PHOENIX	AZ	85009	07/01/2017	04/01/2020
FQHCLA225	SMITHS FOOD & DRUG CENTERS	DBA FRYS FOOD & DRUG #5	7770 E MCDOWELL	SCOTTSDALE	AZ	85257	07/01/2017	04/01/2020
FQHCLA225	SMITHS FOOD & DRUG CENTERS	DBA FRYS FOOD & DRUG #10	4353 W BETHANY HOME ROAD	GLENDALE	AZ	85301	07/01/2017	04/01/2020
FQHCLA225	SMITHS FOOD & DRUG CENTERS	DBA FRYS FOOD & DRUG #623	1815 W. GLENDALE AVENUE	PHOENIX	AZ	85021	07/01/2017	04/01/2020
FQHCLA225	SMITHS FOOD & DRUG CENTERS	DBA FRYS FOOD & DRUG #129	4724 N. 20TH STREET	PHOENIX	AZ	85016	07/01/2017	04/01/2020
FQHCLA225A	SMITHS FOOD AND DRUG CENTERS	DBA FRYS FOOD STORES #11	6710 W. BETHANY HOME RD	GLENDALE	AZ	85303	07/01/2017	04/01/2020
FQHCLA225	SMITHS FOOD AND DRUG CENTERS	DBA FRYS FOOD STORES #11	6710 W. BETHANY HOME RD	GLENDALE	AZ	85303	07/01/2017	04/01/2020
FQHCLA225A	THE KROGER CO.	FRY'S PHARMACY #128	744 W CAMELBACK ROAD	PHOENIX	AZ	85013	07/01/2017	04/01/2020
FQHCLA225	THE KROGER CO.	FRY'S PHARMACY #128	744 W CAMELBACK ROAD	PHOENIX	AZ	85013	07/01/2017	04/01/2020
FQHCLA225	THOMAS PHOENIX CVS, L.L.C.	DBA: CVS/PHARMACY # 03625	8245 W. THOMAS RD.	PHOENIX	AZ	85033	01/01/2019	04/01/2020
FQHCLA225A	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/01/2017	04/01/2020
FQHCLA225	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/01/2017	04/01/2020
FQHCLA225A	WAL-MART PHARMACY 10-1746	1380 WEST ELLIOTT ROAD		TEMPE	AZ	85284	07/01/2017	04/01/2020
FQHCLA225	WAL-MART PHARMACY 10-1746	1380 WEST ELLIOTT ROAD		TEMPE	AZ	85284	07/01/2017	04/01/2020
FQHCLA225A	WAL-MART PHARMACY 10-2112	4915 NORTH PIMA ROAD		SCOTTSDALE	AZ	85251	07/01/2017	04/01/2020
FQHCLA225	WAL-MART PHARMACY 10-2112	4915 NORTH PIMA ROAD		SCOTTSDALE	AZ	85251	07/01/2017	04/01/2020
FQHCLA225A	WAL-MART PHARMACY 10-2113	1607 WEST BETHANY HOME RD		PHOENIX	AZ	85015	07/01/2017	04/01/2020
FQHCLA225	WAL-MART PHARMACY 10-2113	1607 WEST BETHANY HOME RD		PHOENIX	AZ	85015	07/01/2017	04/01/2020
FQHCLA225A	WAL-MART PHARMACY 10-2512	1825 W BELL ROAD		PHOENIX (NORTH)	AZ	85023	07/01/2017	04/01/2020
FQHCLA225	WAL-MART PHARMACY 10-2512	1825 W BELL ROAD		PHOENIX (NORTH)	AZ	85023	07/01/2017	04/01/2020
FQHCLA225A	WAL-MART PHARMACY 10-2515	3721 EAST THOMAS ROAD		PHOENIX (EAST)	AZ	85018	07/01/2017	04/01/2020
FQHCLA225	WAL-MART PHARMACY 10-2515	3721 EAST THOMAS ROAD		PHOENIX (EAST)	AZ	85018	07/01/2017	04/01/2020
FQHCLA225A	WAL-MART PHARMACY 10-3407	1060 SOUTH WATSON		BUCKEYE	AZ	85326	07/01/2017	04/01/2020
FQHCLA225	WAL-MART PHARMACY 10-3407	1060 SOUTH WATSON		BUCKEYE	AZ	85326	07/01/2017	04/01/2020
FQHCLA225A	WAL-MART PHARMACY 10-3799	240 WEST BASELINE ROAD		MESA	AZ	85210	07/01/2017	04/01/2020
FQHCLA225	WAL-MART PHARMACY 10-3799	240 WEST BASELINE ROAD		MESA	AZ	85210	07/01/2017	04/01/2020
FQHCLA225A	WAL-MART PHARMACY 10-4336	12900 WEST THUNDERBIRD		EL MIRAGE	AZ	85335	07/01/2017	04/01/2020
FQHCLA225	WAL-MART PHARMACY 10-4336	12900 WEST THUNDERBIRD		EL MIRAGE	AZ	85335	07/01/2017	04/01/2020
FQHCLA225A	WAL-MART PHARMACY 10-5189	5250 WEST INDIAN SCHOOL RD		PHOENIX (MARYVALE)	AZ	85031	07/01/2017	04/01/2020
FQHCLA225	WAL-MART PHARMACY 10-5189	5250 WEST INDIAN SCHOOL RD		PHOENIX (MARYVALE)	AZ	85031	07/01/2017	04/01/2020
FQHCLA225A	WAL-MART PHARMACY 10-5330	6145 NORTH 35TH AVENUE		PHOENIX	AZ	85017	07/01/2017	04/01/2020
FQHCLA225	WAL-MART PHARMACY 10-5330	6145 NORTH 35TH AVENUE		PHOENIX	AZ	85017	07/01/2017	04/01/2020
FQHCLA225A	WAL-MART PHARMACY 10-5429	14111 N. PRASADA GATEWAY AVE		SURPRISE	AZ	85388	07/01/2017	04/01/2020
FQHCLA225	WAL-MART PHARMACY 10-5429	14111 N. PRASADA GATEWAY AVE		SURPRISE	AZ	85388	07/01/2017	04/01/2020
FQHCLA225A	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/01/2017	04/01/2020
FQHCLA225	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/01/2017	04/01/2020
FQHCLA225A	WELLPARTNER, INC	20800 SW 115TH AVE	SUITE 100	TUALATIN	OR	97062	07/01/2017	04/01/2020
FQHCLA225	WELLPARTNER, INC	20800 SW 115TH AVE	SUITE 100	TUALATIN	OR	97062	07/01/2017	07/04/2018

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	7/1/2018 12:00 AM
Details	Grant Number	Update	Termination Request	LAL000037	LALCS00037	4/19/2018 8:11 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		7/25/2016 12:00:00 AM	4/19/2018 8:11 AM
Details	State	Update	Termination Request	Active	To Be Terminated	4/19/2018 8:11 AM
Terminations	Termination Date	Update	Termination Request		7/1/2018 12:00:00 AM	4/19/2018 8:11 AM
Terminations	Termination Effective Date	Update	Termination Request		7/26/2016 12:00:00 AM	4/19/2018 8:11 AM
Terminations	Termination Reason	Update	Termination Request		Site closure	4/19/2018 8:11 AM
Details	Last Recertification Date	Update	Recertification	2/13/2017 12:00:00 AM	2/8/2018 3:41:43 PM	2/8/2018 3:41 PM
Contacts	Primary Contact	Update	Change Request	Kossick, Joyce Director of Pharmacy Services 6023445253	Holladay, Donald L Assistant Director of Pharmacy Maricopa Integrated Health System 6023448565	10/17/2017 2:33 PM
Contacts	Authorizing Official	Update		Gaw, Kris Chief Operating Officer 6023441258	Gaw, Kris Chief Operating Officer Maricopa Integrated Health Center 6023441258	10/11/2017 2:19 PM
Contacts	Authorizing Official	Insert			Gaw, Kris Chief Operating Officer 6023441258	8/7/2017 11:07 PM
Contacts	Signed By	Insert			Vanaskie, William Executive VP/COO 6023441258	5/25/2017 4:36 PM
Addresses	Main Address	Insert			1616 E. Roeser Road Phoenix, AZ 85040	4/18/2017 8:18 AM
Addresses	Billing Address	Insert			Maricopa Medical Center 2601 E. Roosevelt Phoenix, AZ 85008	4/18/2017 8:18 AM
Addresses	Shipping Address	Insert			South Central FHC Pharmacy 33 W. Tamarisk Phoenix, AZ 85041	4/18/2017 8:18 AM
Details	Entity Subname	Update		Whole Health Home Clinic Choices South Central	SOUTH CENTRAL FHC CLINIC 100501009	4/18/2017 8:17 AM
Details	Last Recertification Date	Update		2/18/2016 12:00:00 AM	2/13/2017 12:00:00 AM	2/13/2017 12:32 PM
Details	Entity Name	Update		MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT	Maricopa County Special Health Care District	5/24/2016 2:27 PM
Details	Last Recertification Date	Update		2/13/2015 12:00:00 AM	2/18/2016 12:00:00 AM	2/18/2016 10:41 AM
Medicaid Billing	Medicaid: Number	Update		020107	946617	1/22/2016 11:58 AM
Medicaid Billing	NPI: Number	Insert			1619396462	1/22/2016 11:58 AM
Contacts	Primary Contact	Update		Mattke, Brad Assistant Director of Pharmacy, Outpatient Services 6023441065	Kossick, Joyce Director of Pharmacy Services 6023445253	10/30/2015 3:03 PM
Details	Entity Subname	Update		Whole Health Clinic Choices South Central	Whole Health Home Clinic Choices South Central	10/28/2015 12:07 PM
Details	Entity Subname	Update		Southcentral FHC IHH Choices - Southcentral	Whole Health Clinic Choices South Central	10/9/2015 9:27 AM
Details	Last Recertification Date	Update		3/16/2014 12:00:00 AM	2/13/2015 12:00:00 AM	2/13/2015 12:43 PM
Contacts	Primary Contact	Insert			Mattke, Brad Assistant Director of Pharmacy, Outpatient Services 6023441065	4/30/2014 10:39 AM
Details	Last Recertification Date	Update			3/16/2014 12:00:00 AM	3/16/2014 9:48 PM
Details	340B ID	Update		IS-FN-FQHCLA225O	FQHCLA225W	2/27/2013 1:03 PM
Dates	Participating Approval Date	Update			2/27/2013 12:00:00 AM	2/27/2013 1:03 PM
Details	State	Update		Pending	Active	2/27/2013 1:03 PM
Dates	Start Date	Update			4/1/2013 12:00:00 AM	2/27/2013 1:03 PM
Details	Grant Number	Update			LAL000037	2/19/2013 3:15 PM
Details	340B ID	Update		ONLINE_REG	IS-FN-FQHCLA225O	2/19/2013 3:15 PM
Details	Entity Name	Update		Maricopa Integrated Health System	MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT	2/19/2013 3:15 PM
Details	Entity Subname	Update		Southcentral FHC IHH Choices Network South Central	Southcentral FHC IHH Choices - Southcentral	2/19/2013 3:15 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/9/2013 7:02 PM
Medicaid Billing	Medicaid: Number	Insert			020107	1/9/2013 7:02 PM
Medicaid Billing	Medicaid: State	Insert			AZ	1/9/2013 7:02 PM
Details	Last Recertification Date	Insert				1/9/2013 7:02 PM
Details	Grant Number	Insert				1/9/2013 7:02 PM
Details	340B ID	Insert			ONLINE_REG	1/9/2013 7:02 PM
Details	Is Authorizing Official EHB Data	Insert				1/9/2013 7:02 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/9/2013 7:02 PM
Details	Medicare Provider Number	Insert				1/9/2013 7:02 PM
Details	Entity Name	Insert			Maricopa Integrated Health System	1/9/2013 7:02 PM
Details	Program Code	Insert			FQHCLA	1/9/2013 7:02 PM
Details	Entity Subname	Insert			Southcentral FHC IHH Choices Network South Central	1/9/2013 7:02 PM
Dates	Participating Approval Date	Insert				1/9/2013 7:02 PM
Details	State	Insert			Pending	1/9/2013 7:02 PM
Dates	Registration Date	Insert			1/9/2013 12:00:00 AM	1/9/2013 7:02 PM
Dates	Signed By Date	Insert			1/9/2013 12:00:00 AM	1/9/2013 7:02 PM
Dates	Start Date	Insert				1/9/2013 7:02 PM
Terminations	Termination Comments	Insert				1/9/2013 7:02 PM
Terminations	Termination Date	Insert				1/9/2013 7:02 PM
Terminations	Termination Effective Date	Insert				1/9/2013 7:02 PM
Terminations	Termination Reason	Insert				1/9/2013 7:02 PM

340B Drug Pricing Program Database