Covered Entity Details

FQHCLA321A Southern California Medical Center (Terminated) - information as of 5/4/2025 10:20:02 PM

Main Details

Name

Southern California Medical Center

Subdivision Name

Southern California Medical Center

Type

Health Center Program Look-Alike

Site ID

BPS-LAL-012827

340B ID

FQHCLA321A

Grant Number

LALCS00144

Additional Details

Current Program Status

Terminated

Registration Date

10/1/2013

Participating Start Date

1/1/2014

Participating Approval Date

11/14/2013

Last Recertification Date

1/28/2015

Termination Date
Termination Reason

1/1/2016
Loss of qualifying grant/support

Contacts

Authorizing Official

Southern California Medical Center
Sheila Busheri, CEO
(818) 324-3780

Primary Contact

Rebecca Casarotti, COO
(562) 699-4477

Addresses

Street Address

12100 Valley Blvd.
El Monte, CA 91732-3100

Billing Address

Southern California Medical Center, Inc.
12100 Valley Blvd Ste 109A
El Monte, CA 91732-3100

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
		1225357114

Shipping Addresses

Shipping Address 1

Southern California Medical Center, Inc.
12100 Valley Blvd Ste 109A
El Monte, CA 91732-3100

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
Contract Detail	ALLIED HEALTH PARTNER INC	DBA ALLIED HEALTH PHARMACY	14659 VICTORY BLVD	VAN NUYS	CA	91411	07/16/2015	10/01/2015		01/01/2016	01/28/2015

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
FQHCLA321	Terminated	BPS-LAL-012828	Southern California Medical Center	Southern California Medical Center	8825 Whittier Blvd.	Pico Rivera	CA
FQHCLA321A	Terminated	BPS-LAL-012827	Southern California Medical Center	Southern California Medical Center	12100 Valley Blvd.	El Monte	CA
FQHCLA321B	Terminated	BPS-LAL-014717	Southern California Medical Center	Southern California Medical Center, Inc.	14550 HAYNES ST	VAN NUYS	CA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
FQHCLA321A	ALLIED HEALTH PARTNER INC	DBA ALLIED HEALTH PHARMACY	14659 VICTORY BLVD	VAN NUYS	CA	91411	10/01/2015	01/01/2016
FQHCLA321B	ALLIED HEALTH PARTNER INC	DBA ALLIED HEALTH PHARMACY	14659 VICTORY BLVD	VAN NUYS	CA	91411	01/01/2019	07/01/2019
FQHCLA321	ALLIED HEALTH PARTNER INC	DBA ALLIED HEALTH PHARMACY	14659 VICTORY BLVD	VAN NUYS	CA	91411	01/01/2019	07/01/2019
FQHCLA321	EL MONTE PHARMACY	3948 N PECK RD STE A1-A2		EL MONTE	CA	91732	07/01/2017	07/01/2019
FQHCLA321	LOS ANGELES COUNTY HEALTH SERVICES CENTRAL PHARMACY	313 N FIGUEROA STREET	SUITE 1225	LOS ANGELES	CA	90012	01/01/2016	07/01/2019
FQHCLA321	MARKET PHARMACY	9250 RESEDA BLVD STE 2C		NORTHRIDGE	CA	91324-5215	10/01/2016	07/01/2019
FQHCLA321	MED-CARE RX PHARMACY	14550 HAYNES ST SUITE #200A		VAN NUYS	CA	91411	07/01/2016	07/01/2019
FQHCLA321	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	04/01/2016	07/01/2019
FQHCLA321	SANTA MARIA PHARMACY INC	DBA SANTA MARIA COMMUNITY PHARMACY	11004 VALLEY MALL	EL MONTE	CA	91731	01/01/2016	07/01/2019
FQHCLA321	WALGREEN CO	DBA: WALGREENS #7575	3643 PECK RD	EL MONTE	CA	91731-3530	07/01/2017	07/01/2019
FQHCLA321	WALGREEN CO.	DBA: WALGREENS # 07598	11907 VALLEY BLVD	EL MONTE	CA	91732-3113	07/01/2017	07/01/2019
FQHCLA321	WALGREEN CO.	DBA: WALGREENS # 07263	8900 WASHINGTON BLVD	PICO RIVERA	CA	90660-3765	07/01/2017	07/01/2019
FQHCLA321	WALGREEN CO.	DBA: WALGREENS # 05525	7155 VAN NUYS BLVD	VAN NUYS	CA	91405	07/01/2017	07/01/2019
FQHCLA321	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #15293	4940 VAN NUYS BLVD STE 104	SHERMAN OAKS	CA	91403	07/01/2017	07/01/2019

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Busheri, Sheila CEO 8183243780	Busheri, Sheila CEO Southern California Medical Center 8183243780	9/20/2017 12:39 PM
Contacts	Signed By	Update	Change Request	Busheri, Sheila CEO 8183243780	Busheri, Sheila CEO Southern California Medical Center 8183243780	9/20/2017 12:39 PM
Contacts	Authorizing Official	Insert			Busheri, Sheila CEO 8183243780	5/16/2017 10:16 AM
Contacts	Signed By	Insert			Busheri, Sheila CEO 8183243780	5/16/2017 10:16 AM
Contacts	Primary Contact	Insert			Casarotti, Rebecca COO 5626994477	12/16/2015 12:55 PM
Dates	Last Date That 340B Drugs Purchased	Update			9/30/2015 12:00:00 AM	10/1/2015 5:27 PM
Details	State	Update		Active	Terminated	10/1/2015 5:27 PM
Terminations	Termination Comments	Update			We are Terminating our FQHC Look-Alike ID FQHC321A because we were granted FQHC 330 status and are now registered as a CHC under this location.	10/1/2015 5:27 PM
Terminations	Termination Date	Update			1/1/2016 12:00:00 AM	10/1/2015 5:27 PM
Terminations	Termination Effective Date	Update			10/1/2015 12:00:00 AM	10/1/2015 5:27 PM
Terminations	Termination Reason	Update			Loss of qualifying grant/support	10/1/2015 5:27 PM
Addresses	Main Address	Insert			12100 Valley Blvd. El Monte, CA 91732-3100	10/1/2015 5:26 PM
Addresses	Billing Address	Insert			Southern California Medical Center, Inc. 12100 Valley Blvd Ste 109A El Monte, CA 91732-3100	10/1/2015 5:26 PM
Addresses	Shipping Address	Insert			Southern California Medical Center, Inc. 12100 Valley Blvd Ste 109A El Monte, CA 91732-3100	10/1/2015 5:26 PM
Details	Grant Number	Update		LAL000144	LALCS00144	10/1/2015 5:26 PM
Details	Last Recertification Date	Update		2/24/2014 12:00:00 AM	1/28/2015 12:00:00 AM	1/28/2015 1:18 PM
Details	Is Authorizing Official EHB Data	Update			False	1/28/2015 1:18 PM
Details	Last Recertification Date	Update			2/24/2014 12:00:00 AM	2/24/2014 10:30 PM
Details	340B ID	Update		LAL000144-01	FQHCLA321A	11/14/2013 12:55 PM
Dates	Participating Approval Date	Update			11/14/2013 12:00:00 AM	11/14/2013 12:55 PM
Details	State	Update		Pending	Active	11/14/2013 12:55 PM
Dates	Start Date	Update			1/1/2014 12:00:00 AM	11/14/2013 12:55 PM
Details	340B ID	Update		ONLINE_REG	LAL000144-01	11/8/2013 5:04 PM
Medicaid Billing	NPI: Number	Insert			1225357114	10/1/2013 5:50 PM
Details	Last Recertification Date	Insert				10/1/2013 5:50 PM
Details	Grant Number	Insert			LAL000144	10/1/2013 5:50 PM
Details	340B ID	Insert			ONLINE_REG	10/1/2013 5:50 PM
Details	Is Authorizing Official EHB Data	Insert				10/1/2013 5:50 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/1/2013 5:50 PM
Details	Medicare Provider Number	Insert				10/1/2013 5:50 PM
Details	Entity Name	Insert			Southern California Medical Center	10/1/2013 5:50 PM
Details	Program Code	Insert			FQHCLA	10/1/2013 5:50 PM
Details	Entity Subname	Insert			Southern California Medical Center	10/1/2013 5:50 PM
Dates	Participating Approval Date	Insert				10/1/2013 5:50 PM
Details	State	Insert			Pending	10/1/2013 5:50 PM
Dates	Registration Date	Insert			10/1/2013 12:00:00 AM	10/1/2013 5:50 PM
Dates	Signed By Date	Insert			10/1/2013 12:00:00 AM	10/1/2013 5:50 PM
Dates	Start Date	Insert				10/1/2013 5:50 PM
Terminations	Termination Comments	Insert				10/1/2013 5:50 PM
Terminations	Termination Date	Insert				10/1/2013 5:50 PM
Terminations	Termination Effective Date	Insert				10/1/2013 5:50 PM
Terminations	Termination Reason	Insert				10/1/2013 5:50 PM

340B Drug Pricing Program Database