Covered Entity Details

CH09879L SANTA ROSA COMMUNITY HEALTH CENTERS (Terminated) - information as of 6/27/2025 12:23:09 AM

Main Details

Name

SANTA ROSA COMMUNITY HEALTH CENTERS

Subdivision Name

Roseland Children's Health Center

Type

HRSA-Funded Health Center

Site ID

BPS-H80-007587

340B ID

CH09879L

Grant Number

H80CS00259

Additional Details

Current Program Status

Terminated

Registration Date

4/11/2014

Participating Start Date

7/1/2014

Participating Approval Date

4/15/2014

Last Recertification Date

3/4/2015

Termination Date
Termination Reason

1/1/2016
Site closure

Contacts

Authorizing Official

Kai Nissley, COO
(707) 303-3600 Ext: 3430

Primary Contact

Kai Nissley, COO
(707) 303-3600 Ext: 3430

Addresses

Street Address

962 Sebastopol Rd
Santa Rosa, CA 95407-6829

Billing Address

Santa Rosa Community Health Centers
3569 Round Barn Circle
Santa Rosa, CA 95403

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	PHA51598
		1962613349,1255600037,1730599697,1770999708,1558512624

Shipping Addresses

Shipping Address 1

Santa Rosa Community Health Centers
3569 Round Barn Circle
Santa Rosa, CA 95403

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	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	01/06/2015	04/01/2015		01/01/2016	03/04/2015
Contract Detail	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	01/06/2015	04/01/2015		01/01/2016	03/04/2015

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH098790	Active	BPS-H80-001086	SANTA ROSA COMMUNITY HEALTH CENTERS	LOMBARDI CAMPUS	751 LOMBARDI COURT STE B	SANTA ROSA	CA
CH09879A	Active	BPS-H80-003880	SANTA ROSA COMMUNITY HEALTH CENTERS	ELSIE ALLEN CAMPUS	599 Bellevue Ave	Santa Rosa	CA
CH09879AA	Terminated	BPS-H80-021715	SANTA ROSA COMMUNITY HEALTH CENTERS	Mobile Van #7 in use as a fixed site	751 Lombardi Court; parked mobile van in parking lot	Santa Rosa	CA
CH09879AB	Terminated	BPS-H80-021782	SANTA ROSA COMMUNITY HEALTH CENTERS	Lombardi Annex (Temp home of Elsie Allen Campus during school maintenance)	789 Lombardi Court Suite 201	Santa Rosa	CA
CH09879AC	Active	BPS-H80-023385	SANTA ROSA COMMUNITY HEALTH CENTERS	Bridge Campus	2235 Challenger Way, Ste 109	Santa Rosa	CA
CH09879AD	Active	BPS-H80-030136	SANTA ROSA COMMUNITY HEALTH CENTERS	Van #2 (ProMaster)	1300 N Dutton Ave	Santa Rosa	CA
CH09879AE	Active	BPS-H80-035660	SANTA ROSA COMMUNITY HEALTH CENTERS	Caritas Campus	301 6th St STE 214	Santa Rosa	CA
CH09879H	Active	BPS-H80-010225	SANTA ROSA COMMUNITY HEALTH CENTERS	VISTA CAMPUS	3569 Round Barn Cir	Santa Rosa	CA
CH09879J	Terminated	BPS-H80-010601	SANTA ROSA COMMUNITY HEALTH CENTERS	Brookwood Health Center	983 Sonoma Ave	Santa Rosa	CA
CH09879K	Active	BPS-H80-011935	SANTA ROSA COMMUNITY HEALTH CENTERS	Pediatric Campus	711 Stony Point Rd STE 17	Santa Rosa	CA
CH09879L	Terminated	BPS-H80-007587	SANTA ROSA COMMUNITY HEALTH CENTERS	Roseland Children's Health Center	962 Sebastopol Rd	Santa Rosa	CA
CH09879M	Terminated	BPS-H80-006137	SANTA ROSA COMMUNITY HEALTH CENTERS	TURNING POINT SATELLITE	440 ARROWOOD DR	SANTA ROSA	CA
CH09879N	Terminated	BPS-H80-010998	SANTA ROSA COMMUNITY HEALTH CENTERS	Santa Rosa Junior College Health Center	1501 Mendocino Avenue BLDG Race	Santa Rosa	CA
CH09879P	Terminated	BPS-H80-011206	SANTA ROSA COMMUNITY HEALTH CENTERS	Bridge Health Clinic	3333 Chanate Avenue	Santa Rosa	CA
CH09879Q	Active	BPS-H80-013022	SANTA ROSA COMMUNITY HEALTH CENTERS	DENTAL CAMPUS	1110 N Dutton Ave	Santa Rosa	CA
CH09879R	Terminated	BPS-H80-013023	SANTA ROSA COMMUNITY HEALTH CENTERS	Santa Rosa Mobile Clinic	parked overnight at 3569 Round Barn Circle	Santa Rosa	CA
CH09879S	Terminated	BPS-H80-014341	SANTA ROSA COMMUNITY HEALTH CENTERS	St. Joseph's Dental Clinic	751 LOMBARDI CT	SANTA ROSA	CA
CH09879T	Terminated	BPS-H80-021334	SANTA ROSA COMMUNITY HEALTH CENTERS	TEMPORARY SITE-Santa Rosa Community Health Center Mobile Clinic 2	751 Lombardi Ct	Santa Rosa	CA
CH09879U	Terminated	BPS-H80-021336	SANTA ROSA COMMUNITY HEALTH CENTERS	Santa Rosa Community Health Center Mobile Clinic 3-TEMPORARY	751 Lombardi Ct	Santa Rosa	CA
CH09879V	Terminated	BPS-H80-021335	SANTA ROSA COMMUNITY HEALTH CENTERS	TEMPORARY-Santa Rosa Community Health Center Mobile Clinic 1	751 Lombardi Ct	Santa Rosa	CA
CH09879W	Terminated	BPS-H80-021513	SANTA ROSA COMMUNITY HEALTH CENTERS	Van #1 (Tiburcio)	1110 N Dutton Ave	Santa Rosa	CA
CH09879X	Active	BPS-H80-018048	SANTA ROSA COMMUNITY HEALTH CENTERS	Dutton Campus	1300 N Dutton Avenue	Santa Rosa	CA
CH09879Y	Terminated	BPS-H80-021848	SANTA ROSA COMMUNITY HEALTH CENTERS	Airway Campus	3883 Airway Drive	Santa Rosa	CA
CH09879Z	Terminated	BPS-H80-021714	SANTA ROSA COMMUNITY HEALTH CENTERS	Mobile Van #2 in use as a fixed site	751 Lombardi Court	Santa Rosa	CA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH098790	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	01/01/2024
CH098790	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	01/01/2024
CH098790	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	01/01/2024
CH098790	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	01/01/2024
CH098790	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	01/01/2024
CH098790	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	01/01/2024
CH098790	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	01/01/2024
CH098790	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	01/01/2024
CH098790	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	01/01/2024
CH098790	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	01/01/2024
CH098790	CREEKSIDE PHARMACY	95 MONTGOMERY DR.	STE. 108	SANTA ROSA	CA	95404	07/01/2024
CH098790	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	01/01/2024
CH098790	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	01/01/2024
CH098790	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	01/01/2024
CH098790	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17646	950 CODDINGTOWN CENTER	SANTA ROSA	CA	95401	04/01/2021
CH098790	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16293	475 ROHNERT PARK EXPY W	ROHNERT PARK	CA	94928	04/01/2021
CH098790	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16356	1980 SANTA ROSA AVE	SANTA ROSA	CA	95407	04/01/2021
CH098790	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY #11346	101 W LAKE ST	MOUNT SHASTA	CA	96067-2225	01/01/2022	10/16/2023
CH098790	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY # 10080	1059 HYDE ST.	SAN FRANCISCO	CA	94109	01/01/2022	10/16/2023
CH098790	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09652	8491 SANTA MONICA BLVD	WEST HOLLYWOOD	CA	90069	01/01/2022	10/16/2023
CH098790	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08943	102 S. SANDERSON AVE.	SAN JACINTO	CA	92582	01/01/2022	10/16/2023
CH098790	LARK REXALL DRUGS INC	DBA LARK DRUGS PHARMACY	16251 MAIN ST	GUERNEVILLE	CA	95446-8300	10/14/2014
CH09879H	LARK REXALL DRUGS INC	DBA LARK DRUGS PHARMACY	16251 MAIN ST	GUERNEVILLE	CA	95446-8300	10/14/2014	07/01/2024
CH09879Q	LARK REXALL DRUGS INC	DBA LARK DRUGS PHARMACY	16251 MAIN ST	GUERNEVILLE	CA	95446-8300	07/01/2015	07/01/2024
CH09879W	LARK REXALL DRUGS INC	DBA LARK DRUGS PHARMACY	16251 MAIN ST	GUERNEVILLE	CA	95446-8300	12/13/2017	10/01/2019
CH09879T	LARK REXALL DRUGS INC	DBA LARK DRUGS PHARMACY	16251 MAIN ST	GUERNEVILLE	CA	95446-8300	12/13/2017	04/01/2019
CH09879U	LARK REXALL DRUGS INC	DBA LARK DRUGS PHARMACY	16251 MAIN ST	GUERNEVILLE	CA	95446-8300	01/01/2018	04/01/2019
CH09879V	LARK REXALL DRUGS INC	DBA LARK DRUGS PHARMACY	16251 MAIN ST	GUERNEVILLE	CA	95446-8300	01/01/2018	04/01/2019
CH09879T	LARK REXALL DRUGS INC	DBA LARK DRUGS PHARMACY	16251 MAIN ST	GUERNEVILLE	CA	95446-8300	01/01/2018	04/01/2019
CH09879AC	LARK REXALL DRUGS INC	DBA LARK DRUGS PHARMACY	16251 MAIN ST	GUERNEVILLE	CA	95446-8300	01/01/2019	07/01/2024
CH09879AD	LARK REXALL DRUGS INC	DBA LARK DRUGS PHARMACY	16251 MAIN ST	GUERNEVILLE	CA	95446-8300	07/01/2020	07/01/2024
CH09879W	LARK REXALL DRUGS INC	DBA LARK DRUGS PHARMACY	16251 MAIN ST	GUERNEVILLE	CA	95446-8300	07/01/2020	04/01/2023
CH09879K	LARK REXALL DRUGS INC	DBA LARK DRUGS PHARMACY	16251 MAIN ST	GUERNEVILLE	CA	95446-8300	01/01/2024	07/01/2024
CH09879AE	LARK REXALL DRUGS INC	DBA LARK DRUGS PHARMACY	16251 MAIN ST	GUERNEVILLE	CA	95446-8300	01/01/2024	07/01/2024
CH09879A	LARK REXALL DRUGS INC	DBA LARK DRUGS PHARMACY	16251 MAIN ST	GUERNEVILLE	CA	95446-8300	01/01/2024	07/01/2024
CH09879X	LARK REXALL DRUGS INC	DBA LARK DRUGS PHARMACY	16251 MAIN ST	GUERNEVILLE	CA	95446-8300	01/01/2024	07/01/2024
CH09879S	LARK REXALL DRUGS INC	DBA LARK DRUGS PHARMACY	16251 MAIN ST	GUERNEVILLE	CA	95446-8300	01/01/2024	04/01/2024
CH09879S	LOMBARDI ROSA PHARMACY		751B LOMBARDI CT	SANTA ROSA	CA	95407	01/01/2016	10/16/2023
CH09879AC	LOMBARDI ROSA PHARMACY		751B LOMBARDI CT	SANTA ROSA	CA	95407	01/01/2019	10/16/2023
CH09879AD	LOMBARDI ROSA PHARMACY		751B LOMBARDI CT	SANTA ROSA	CA	95407	07/01/2020	10/16/2023
CH09879W	LOMBARDI ROSA PHARMACY		751B LOMBARDI CT	SANTA ROSA	CA	95407	07/01/2020	04/01/2023
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09928	6378 COMMERCE BLVD	ROHNERT PARK	CA	94928	04/01/2021
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09948	2700 YULUPA AVE	SANTA ROSA	CA	95405	04/01/2021
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09529	442 LAS GALLINAS AVE	SAN RAFAEL	CA	94903	04/01/2021	10/16/2023
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09393	2075 MENDOCINO AVE	SANTA ROSA	CA	95401	04/01/2021
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09872	6877 SEBASTOPOL AVENUE	SEBASTOPOL	CA	95472	04/01/2021
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09946	463 STONY POINT RD	SANTA ROSA	CA	95401	04/01/2021
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 01173	455 CENTER ST	HEALDSBURG	CA	95448	04/01/2021
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09931	9030 BROOKS RD S	WINDSOR	CA	95492	04/01/2021
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09656	2771 4TH ST	SANTA ROSA	CA	95405	04/01/2021
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09378	4100 REDWOOD RD	OAKLAND	CA	94619	01/01/2022	10/16/2023
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09159	1109 COUNTRY CLUB DR	MADERA	CA	93638	01/01/2022	10/16/2023
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 01804	675 TRANCAS ST	NAPA	CA	94558	01/01/2022
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09371	300 TRAVIS BLVD	FAIRFIELD	CA	94533	01/01/2022	10/16/2023
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 00345	1111 S CLOVERDALE BLVD	CLOVERDALE	CA	95425	01/01/2022
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09823	1350 FLORIN ROAD	SACRAMENTO	CA	95822	01/01/2022
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09163	291 N MCDOWELL BLVD	PETALUMA	CA	94954	01/01/2022
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09987	1798 MIRAMONTE AVE	MOUNTAIN VIEW	CA	94040	01/01/2022
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09152	201 W NAPA ST STE 35	SONOMA	CA	95476	01/01/2022
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 03939	800 W HARRIS ST STE 20	EUREKA	CA	95503	01/01/2022	10/16/2023
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09480	365 E WASHINGTON ST	PETALUMA	CA	94952	01/01/2022
CH098790	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09943	949 11TH ST	LAKEPORT	CA	95453	01/01/2022
CH098790	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	04/01/2015
CH098790	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	04/01/2015
CH09879H	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	04/01/2015	07/01/2024
CH09879H	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	04/01/2015	07/01/2024
CH09879A	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	04/01/2015	07/01/2024
CH09879A	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	04/01/2015	07/01/2024
CH09879J	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	04/01/2015	04/01/2023
CH09879J	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	04/01/2015	04/01/2023
CH09879K	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	04/01/2015	07/01/2024
CH09879K	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	04/01/2015	07/01/2024
CH09879Q	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	04/01/2015	07/01/2024
CH09879Q	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	04/01/2015	07/01/2024
CH09879P	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	04/01/2015	04/01/2019
CH09879P	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	04/01/2015	04/01/2019
CH09879N	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	04/01/2015	04/01/2020
CH09879N	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	04/01/2015	04/01/2020
CH09879M	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	04/01/2015	04/01/2019
CH09879M	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	04/01/2015	04/01/2019
CH09879L	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	04/01/2015	01/01/2016
CH09879L	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	04/01/2015	01/01/2016
CH09879R	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	04/01/2015	04/01/2018
CH09879R	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	04/01/2015	04/01/2018
CH09879U	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	12/13/2017	04/01/2019
CH09879T	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	01/01/2018	04/01/2019
CH09879V	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	01/01/2018	04/01/2019
CH09879W	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	01/01/2018	10/01/2019
CH09879Z	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	01/01/2019	04/01/2019
CH09879Y	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	01/01/2019	10/01/2019
CH09879Y	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	01/01/2019	10/01/2019
CH09879Z	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	01/01/2019	04/01/2019
CH09879X	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	01/01/2019	07/01/2024
CH09879Z	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	01/01/2019	04/01/2019
CH09879Z	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	01/01/2019	04/01/2019
CH09879X	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	01/01/2019	07/01/2024
CH09879W	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	01/01/2019	10/01/2019
CH09879AC	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	01/01/2019	07/01/2024
CH09879AC	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	01/01/2019	10/16/2023
CH09879AC	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	01/01/2019	07/01/2024
CH09879W	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	07/01/2020	04/01/2023
CH09879AD	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	07/01/2020	07/01/2024
CH09879AD	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	01/01/2024	07/01/2024
CH09879S	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	01/01/2024	04/01/2024
CH09879AE	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	01/01/2024	07/01/2024
CH09879AE	MARIN APOTHECARIES, INC.	LOMBARDI ROSA PHARMACY	751 LOMBARDI CT SUITE 100	SANTA ROSA	CA	95407-6798	01/01/2024	07/01/2024
CH09879S	MARIN APOTHECARIES, INC.	DUTTON COMMUNITY PHARMACY	1300 NORTH DUTTON AVENUE SUITE 100	SANTA ROSA	CA	95401	01/01/2024	04/01/2024
CH098790	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	01/01/2024
CH098790	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY	445 CASTRO STREET	SAN FRANCISCO	CA	94114	01/01/2022
CH098790	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	01/01/2024
CH098790	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	01/01/2024
CH09879H	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2019	07/01/2024
CH09879Q	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2019	07/01/2024
CH09879T	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2019	04/01/2019
CH09879Y	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2019	10/01/2019
CH09879W	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2019	10/01/2019
CH09879J	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2019	04/01/2023
CH09879N	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2019	04/01/2020
CH09879J	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2019	04/01/2023
CH09879Z	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2019	04/01/2019
CH098790	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2019
CH09879K	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2019	07/01/2024
CH09879V	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2019	04/01/2019
CH09879P	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2019	04/01/2019
CH09879X	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2019	07/01/2024
CH09879S	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2019	04/01/2024
CH09879AA	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2019	04/01/2019
CH09879A	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2019	07/01/2024
CH09879Y	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2019	10/01/2019
CH09879U	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2019	04/01/2019
CH09879AD	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	07/01/2020	07/01/2024
CH09879W	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	07/01/2020	04/01/2023
CH09879AE	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2024	07/01/2024
CH09879AC	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	01/01/2024	07/01/2024
CH098790	THRIFTY PAYLESS, INC.	RITE AID #4212	955 STONY POINT ROAD	SANTA ROSA	CA	95407	07/01/2024	04/29/2025
CH098790	THRIFTY PAYLESS, INC.	RITE AID #6023	1551 FARMERS LANE	SANTA ROSA	CA	95405	07/01/2024	04/29/2025
CH098790	THRIFTY PAYLESS, INC.	RITE AID #6029	525 HEALDSBURG AVENUE	HEALDSBURG	CA	95448	07/01/2024	04/29/2025
CH098790	THRIFTY PAYLESS, INC.	RITE AID #6031	218 NORTH MAIN STREET	SEBASTOPOL	CA	95472	07/01/2024	04/29/2025
CH098790	THRIFTY PAYLESS, INC.	RITE AID #5880	540 CANAL STREET	KING CITY	CA	93930	07/01/2024	04/29/2025
CH09879J	VISTA CLINIC PHARMACY	3569A ROUND BARN CIRCLE		SANTA ROSA	CA	95403	07/01/2020	04/01/2023
CH09879AC	VISTA CLINIC PHARMACY	3569A ROUND BARN CIRCLE		SANTA ROSA	CA	95403	07/01/2020	07/01/2024
CH09879X	VISTA CLINIC PHARMACY	3569A ROUND BARN CIRCLE		SANTA ROSA	CA	95403	07/01/2020	07/01/2024
CH098790	VISTA CLINIC PHARMACY	3569A ROUND BARN CIRCLE		SANTA ROSA	CA	95403	04/15/2020
CH09879A	VISTA CLINIC PHARMACY	3569A ROUND BARN CIRCLE		SANTA ROSA	CA	95403	07/01/2020	07/01/2024
CH09879K	VISTA CLINIC PHARMACY	3569A ROUND BARN CIRCLE		SANTA ROSA	CA	95403	07/01/2020	07/01/2024
CH09879S	VISTA CLINIC PHARMACY	3569A ROUND BARN CIRCLE		SANTA ROSA	CA	95403	07/01/2020	04/01/2024
CH09879H	VISTA CLINIC PHARMACY	3569A ROUND BARN CIRCLE		SANTA ROSA	CA	95403	07/01/2020	07/01/2024
CH09879Q	VISTA CLINIC PHARMACY	3569A ROUND BARN CIRCLE		SANTA ROSA	CA	95403	07/01/2020	07/01/2024
CH09879W	VISTA CLINIC PHARMACY	3569A ROUND BARN CIRCLE		SANTA ROSA	CA	95403	07/01/2020	04/01/2023
CH09879AD	VISTA CLINIC PHARMACY	3569A ROUND BARN CIRCLE		SANTA ROSA	CA	95403	07/01/2020	07/01/2024
CH09879AE	VISTA CLINIC PHARMACY	3569A ROUND BARN CIRCLE		SANTA ROSA	CA	95403	01/01/2024	07/01/2024
CH09879S	VISTA ROSA PHARMACY		3569 ROUND BARN CIRCLE	SANTA ROSA	CA	95403	01/01/2016	10/16/2023

History

Section	Field	Action	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Insert		Nissley, Kai COO 7073033600-3430	5/2/2017 1:19 PM
Contacts	Primary Contact	Insert		Nissley, Kai COO 7073033600-3430	5/2/2017 1:19 PM
Contacts	Signed By	Insert		Nissley, Kai COO 7073033600-3430	5/2/2017 1:19 PM
Dates	Last Date That 340B Drugs Purchased	Update		6/30/2013 12:00:00 AM	10/8/2015 5:04 PM
Details	State	Update	Active	Terminated	10/8/2015 5:04 PM
Terminations	Termination Comments	Update		340B medications were not purchased for this site.	10/8/2015 5:04 PM
Terminations	Termination Date	Update		1/1/2016 12:00:00 AM	10/8/2015 5:04 PM
Terminations	Termination Effective Date	Update		7/1/2013 12:00:00 AM	10/8/2015 5:04 PM
Terminations	Termination Reason	Update		Site closure	10/8/2015 5:04 PM
Addresses	Main Address	Insert		962 Sebastopol Rd Santa Rosa, CA 95407-6829	10/8/2015 5:04 PM
Addresses	Billing Address	Insert		Santa Rosa Community Health Centers 3569 Round Barn Circle Santa Rosa, CA 95403	10/8/2015 5:04 PM
Addresses	Shipping Address	Insert		Santa Rosa Community Health Centers 3569 Round Barn Circle Santa Rosa, CA 95403	10/8/2015 5:04 PM
Details	Last Recertification Date	Update		3/4/2015 12:00:00 AM	3/4/2015 1:31 PM
Medicaid Billing	NPI: Number	Insert		1770999708	10/14/2014 1:39 PM
Medicaid Billing	NPI: Number	Insert		1558512624	10/14/2014 1:39 PM
Details	Is Authorizing Official EHB Data	Update		False	10/14/2014 1:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert		False	6/5/2014 9:42 AM
Medicaid Billing	Medicaid: Number	Insert		PHA51598	6/5/2014 9:42 AM
Medicaid Billing	Medicaid: State	Insert		CA	6/5/2014 9:42 AM
Medicaid Billing	NPI: Number	Insert		1730599697	6/5/2014 9:42 AM
Details	340B ID	Update	ONLINE_REG	CH09879L	4/15/2014 2:28 PM
Dates	Participating Approval Date	Update		4/15/2014 12:00:00 AM	4/15/2014 2:28 PM
Details	State	Update	Pending	Active	4/15/2014 2:28 PM
Dates	Start Date	Update		7/1/2014 12:00:00 AM	4/15/2014 2:28 PM
Medicaid Billing	NPI: Number	Insert		1962613349	4/11/2014 7:19 PM
Medicaid Billing	NPI: Number	Insert		1255600037	4/11/2014 7:19 PM
Details	Last Recertification Date	Insert			4/11/2014 7:19 PM
Details	Grant Number	Insert		H80CS00259	4/11/2014 7:19 PM
Details	340B ID	Insert		ONLINE_REG	4/11/2014 7:19 PM
Details	Is Authorizing Official EHB Data	Insert			4/11/2014 7:19 PM
Dates	Last Date That 340B Drugs Purchased	Insert			4/11/2014 7:19 PM
Details	Medicare Provider Number	Insert			4/11/2014 7:19 PM
Details	Entity Name	Insert		SANTA ROSA COMMUNITY HEALTH CENTERS	4/11/2014 7:19 PM
Details	Program Code	Insert		CH	4/11/2014 7:19 PM
Details	Entity Subname	Insert		Roseland Children's Health Center	4/11/2014 7:19 PM
Dates	Participating Approval Date	Insert			4/11/2014 7:19 PM
Details	State	Insert		Pending	4/11/2014 7:19 PM
Dates	Registration Date	Insert		4/11/2014 12:00:00 AM	4/11/2014 7:19 PM
Dates	Signed By Date	Insert		4/11/2014 12:00:00 AM	4/11/2014 7:19 PM
Dates	Start Date	Insert			4/11/2014 7:19 PM
Terminations	Termination Comments	Insert			4/11/2014 7:19 PM
Terminations	Termination Date	Insert			4/11/2014 7:19 PM
Terminations	Termination Effective Date	Insert			4/11/2014 7:19 PM
Terminations	Termination Reason	Insert			4/11/2014 7:19 PM

340B Drug Pricing Program Database