Covered Entity Details

FQHCLA311A Greater Fresno Health Organization (Active) - information as of 4/25/2025 5:39:21 PM

Main Details

Name

Greater Fresno Health Organization

Subdivision Name

North Marks Medical Clinic

Type

Health Center Program Look-Alike

Site ID

BPS-LAL-013858

340B ID

FQHCLA311A

Grant Number

LALCS00041

Additional Details

Current Program Status

Active

Registration Date

7/13/2018

Participating Start Date

10/1/2018

Participating Approval Date

8/1/2018

Last Recertification Date

2/10/2025

Contacts

Authorizing Official

GREATER FRESNO HEALTH ORGANIZATION
BLA MOUANOUTOUA, CEO
(559) 255-6476 Ext: 4290

Primary Contact

Greater Fresno Health Organization
Torey Lam, 340B Manager
(808) 499-5491

Addresses

Street Address

4011 N Marks Ave
Fresno, CA 93722-4555

Billing Address
Same as Street Address

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

Comments

Comment	Last Updated On
Participating from effective date (10/1/2014) until terminated effective date (4/1/2018), reinstatement date effective date (10/01/2018)	07/31/2018

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
No

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	FRESNO PHARMACY	4917 E KINGS CANYON ROAD	NO 102	FRESNO	CA	93727	04/15/2019	07/01/2019	04/01/2018	02/12/2024
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 05422	5180 E. KINGS CANYON ROAD	FRESNO	CA	93727	01/15/2024	04/01/2024		04/01/2024
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5872	5574 EAST KINGS CANYON	FRESNO	CA	93727	04/08/2024	07/01/2024		07/01/2024
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #6289	4593 NORTH CEDAR AVENUE	FRESNO	CA	93726	04/08/2024	07/01/2024		07/01/2024

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
FQHCLA311	Active	BPS-LAL-009767	Greater Fresno Health Organization	Kings Winery Medical Clinic	4929 E Cesar Chavez Blvd	Fresno	CA
FQHCLA311A	Active	BPS-LAL-013858	Greater Fresno Health Organization	North Marks Medical Clinic	4011 N Marks Ave	Fresno	CA
FQHCLA311B	Active	BPS-LAL-021855	Greater Fresno Health Organization	Cedar University Clinic	4770 N Cedar Ave	Fresno	CA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
FQHCLA311	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	10/01/2023
FQHCLA311	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	10/01/2023
FQHCLA311	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	10/01/2023
FQHCLA311	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	10/01/2023
FQHCLA311	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	10/01/2023
FQHCLA311	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	10/01/2023
FQHCLA311	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	10/01/2023
FQHCLA311	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	10/01/2023
FQHCLA311	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	10/01/2023
FQHCLA311	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	10/01/2023
FQHCLA311	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	10/01/2023
FQHCLA311	FRESNO PHARMACY	4917 E KINGS CANYON ROAD	NO 102	FRESNO	CA	93727	04/01/2014	04/01/2018
FQHCLA311A	FRESNO PHARMACY	4917 E KINGS CANYON ROAD	NO 102	FRESNO	CA	93727	07/01/2019	04/01/2018
FQHCLA311B	FRESNO PHARMACY	4917 E KINGS CANYON ROAD	NO 102	FRESNO	CA	93727	07/01/2019	04/01/2018
FQHCLA311	FRESNO PHARMACY	4917 E KINGS CANYON ROAD	NO 102	FRESNO	CA	93727	07/01/2019	12/31/2020
FQHCLA311	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17111	695 W HERNDON AVE	CLOVIS	CA	93612	10/01/2023
FQHCLA311	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17614	6655 NORTH RIVERSIDE DR	FRESNO	CA	93722	10/01/2023
FQHCLA311	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16755	5740 N BLACKSTONE AVE	FRESNO	CA	93710	10/01/2023
FQHCLA311	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10074	5995 EAST KINGS CANYON RD	FRESNO	CA	93727	10/01/2023
FQHCLA311	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 05422	5180 E. KINGS CANYON ROAD	FRESNO	CA	93727	10/01/2023
FQHCLA311	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 06772	4987 N. FRESNO ST.	FRESNO	CA	93726	10/01/2023
FQHCLA311	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY # 11339	777 S. HARBOR BLVD., SUITE E-164	LA HABRA	CA	90631	10/01/2023	02/19/2024
FQHCLA311	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16108	3173 E SHIELDS AVE	FRESNO	CA	93726	10/01/2023
FQHCLA311	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10801	6720 N. FRESNO ST.	FRESNO	CA	93710	10/01/2023
FQHCLA311	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16084	3150 W SHAW AVE	FRESNO	CA	93711	10/01/2023
FQHCLA311A	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 05422	5180 E. KINGS CANYON ROAD	FRESNO	CA	93727	04/01/2024
FQHCLA311	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09149	6750 N CEDAR AVE	FRESNO	CA	93710	10/01/2023
FQHCLA311	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09537	1325 W SHIELDS AVENUE	FRESNO	CA	93705	10/01/2023
FQHCLA311	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09971	4077 W CLINTON AVE	FRESNO	CA	93722	10/01/2023	09/20/2023
FQHCLA311	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09801	10 SHAW AVE	CLOVIS	CA	93612	10/01/2023
FQHCLA311	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09846	6800 N MILBURN AVE	FRESNO	CA	93722	10/01/2023
FQHCLA311	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 03925	2133 SHAW AVE	CLOVIS	CA	93611	10/01/2023
FQHCLA311	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 03940	1107 N WILLOW AVE	CLOVIS	CA	93611	10/01/2023
FQHCLA311	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 07553	3011 E SHIELDS AVE	FRESNO	CA	93726	10/01/2023
FQHCLA311	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 07910	1794 ASHLAN AVE	CLOVIS	CA	93611	10/01/2023
FQHCLA311	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09994	728 W SHAW AVE	FRESNO	CA	93704	10/01/2023
FQHCLA311	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	10/01/2023
FQHCLA311	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	10/01/2023
FQHCLA311	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	10/01/2023
FQHCLA311	THE MEDICINE SHOPPE PHCY	4009 N MARKS AVE		FRESNO	CA	93722	10/01/2014	04/01/2018
FQHCLA311A	THRIFTY PAYLESS, INC.	RITE AID #5872	5574 EAST KINGS CANYON	FRESNO	CA	93727	07/01/2024
FQHCLA311B	THRIFTY PAYLESS, INC.	RITE AID #5872	5574 EAST KINGS CANYON	FRESNO	CA	93727	07/01/2024
FQHCLA311B	THRIFTY PAYLESS, INC.	RITE AID #6289	4593 NORTH CEDAR AVENUE	FRESNO	CA	93726	07/01/2024
FQHCLA311A	THRIFTY PAYLESS, INC.	RITE AID #6289	4593 NORTH CEDAR AVENUE	FRESNO	CA	93726	07/01/2024
FQHCLA311	THRIFTY PAYLESS, INC.	RITE AID #5872	5574 EAST KINGS CANYON	FRESNO	CA	93727	07/01/2024
FQHCLA311	THRIFTY PAYLESS, INC.	RITE AID #6289	4593 NORTH CEDAR AVENUE	FRESNO	CA	93726	07/01/2024
FQHCLA311	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	10/01/2023
FQHCLA311	WAL-MART PHARMACY 10-1815	4080 W SHAW AVE		FRESNO	CA	93722	10/01/2023
FQHCLA311B	WAL-MART PHARMACY 10-1815	4080 W SHAW AVE		FRESNO	CA	93722	04/01/2024
FQHCLA311	WAL-MART PHARMACY 10-2001	5125 EAST KINGS CANYON		FRESNO	CA	93727	10/01/2023
FQHCLA311	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	10/01/2023
FQHCLA311	WALGREEN CO	DBA: WALGREENS #09702	5785 N FIRST ST	FRESNO	CA	93710-6203	04/01/2024
FQHCLA311	WALGREEN CO	DBA: WALGREENS #10243	2420 N BLACKSTONE AVE	FRESNO	CA	93703-1747	04/01/2024	01/18/2025
FQHCLA311	WALGREEN CO	DBA: WALGREENS #10335	2424 N BRAWLEY AVE	FRESNO	CA	93722	04/01/2024
FQHCLA311	WALGREEN CO.	DBA: WALGREENS # 06082	626 S CLOVIS AVE	FRESNO	CA	93727	04/01/2024
FQHCLA311	WALGREEN CO.	DBA WALGREENS #06386	4810 E CESAR CHAVEZ BLVD	FRESNO	CA	93727	04/01/2024
FQHCLA311	WALGREEN CO.	DBA: WALGREENS # 06387	1815 HERNDON AVE	CLOVIS	CA	93611	04/01/2024
FQHCLA311	WALGREEN CO.	DBA: WALGREENS # 06942	6010 N FIGARDEN DRIVE	FRESNO	CA	93722-6030	04/01/2024
FQHCLA311	WALGREEN CO.	DBA: WALGREENS # 07830	205 W SHAW AVENUE	CLOVIS	CA	93612-3602	04/01/2024
FQHCLA311	WALGREEN CO.	DBA: WALGREENS # 10334	1790 SHAW AVE	CLOVIS	CA	93611	04/01/2024
FQHCLA311	WALGREEN CO.	DBA: WALGREENS #12574	1219 N CEDAR AVE	FRESNO	CA	93703	04/01/2024
FQHCLA311	WALGREEN CO.	DBA: WALGREENS # 12707	4172 N. 1ST STREET	FRESNO	CA	93726	04/01/2024
FQHCLA311	WALGREEN CO.	DBA: WALGREENS # 13871	1016 W SHAW AVE	FRESNO	CA	93711	04/01/2024
FQHCLA311	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	10/01/2023	01/01/2023
FQHCLA311	WALMART PHARMACY 10-5632	1804 EAST ASHLAN AVE.		FRESNO	CA	93726	10/01/2023
FQHCLA311	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	1/29/2024 2:07:16 PM	2/10/2025 8:42:46 PM	2/10/2025 8:42 PM
Details	Last Recertification Date	Update	Recertification	1/30/2023 6:23:31 PM	1/29/2024 2:07:16 PM	1/29/2024 2:07 PM
Contacts	Primary Contact	Update	Change Request	Yang, Paul CFO Greater Fresno Health Org. Inc. 5592556476	Lam, Torey 340B Manager Greater Fresno Health Organization 8084995491	1/16/2024 7:57 AM
Details	Last Recertification Date	Update	Recertification	2/1/2022 8:32:32 PM	1/30/2023 6:23:31 PM	1/30/2023 6:23 PM
Details	Last Recertification Date	Update	Recertification	2/17/2021 6:45:39 PM	2/1/2022 8:32:32 PM	2/1/2022 8:32 PM
Details	Last Recertification Date	Update	Recertification	2/4/2020 7:22:03 PM	2/17/2021 6:45:39 PM	2/17/2021 6:45 PM
Contacts	Authorizing Official	Update	AO Change Request	Bliatout, Bobby CEO Greater Fresno Health Organization Inc 5592556476	MOUANOUTOUA, BLA CEO GREATER FRESNO HEALTH ORGANIZATION 5592556476-4290	2/16/2021 1:44 PM
Details	Last Recertification Date	Update	Recertification	1/29/2019 2:24:57 AM	2/4/2020 7:22:03 PM	2/4/2020 7:22 PM
Terminations	Termination Reason	Update		Failure to recertify		5/23/2019 3:13 PM
Details	Grant Number	Update	OPA Edit	LAL000041	LALCS00041	5/3/2019 2:40 PM
Details	Last Recertification Date	Update	Recertification	2/22/2017 12:00:00 AM	1/29/2019 2:24:57 AM	1/29/2019 2:24 AM
Details	State	Update		Approved	Active	10/1/2018 12:05 AM
Addresses	Main Address	Insert	Reinstatement		4011 N Marks Ave Fresno, CA 93722-4555	8/1/2018 8:07 AM
Contacts	Primary Contact	Update	Reinstatement	Bliatout, Bobby CEO Greater Fresno Health Organization Inc 5592556476	Yang, Paul CFO Greater Fresno Health Org. Inc. 5592556476	8/1/2018 8:07 AM
Details	Grant Number	Update	Reinstatement	LALCS00041	LAL000041	8/1/2018 8:07 AM
Details	Is Authorizing Official EHB Data	Update	Reinstatement	False		8/1/2018 8:07 AM
Dates	Participating Approval Date	Update	Reinstatement		8/1/2018 8:07:34 AM	8/1/2018 8:07 AM
Details	State	Update	Reinstatement	Pending	Approved	8/1/2018 8:07 AM
Dates	Signed By Date	Update	Reinstatement	7/7/2014 12:00:00 AM	7/13/2018 3:58:28 PM	8/1/2018 8:07 AM
Dates	Start Date	Update	Reinstatement		10/1/2018 12:00:00 AM	8/1/2018 8:07 AM
Terminations	Termination Reason	Update	Reinstatement		Failure to recertify	8/1/2018 8:07 AM
Details	Comments Public	Insert	Reinstatement		Participating from effective date (10/1/2014) until terminated effective date (4/1/2018), reinstatement date effective date (10/01/2018)	7/31/2018 12:18 PM
Details	Grant Number	Update	Reinstatement	LAL000041	LALCS00041	7/13/2018 3:58 PM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	4/1/2018 12:00:00 AM		7/13/2018 3:58 PM
Dates	Participating Approval Date	Update	Reinstatement	7/29/2014 12:00:00 AM		7/13/2018 3:58 PM
Details	State	Update	Reinstatement	Terminated	Pending	7/13/2018 3:58 PM
Dates	Registration Date	Update	Reinstatement	7/7/2014 12:00:00 AM	7/13/2018 3:58:26 PM	7/13/2018 3:58 PM
Dates	Start Date	Update	Reinstatement	10/1/2014 12:00:00 AM		7/13/2018 3:58 PM
Terminations	Termination Date	Update	Reinstatement	4/1/2018 12:00:00 AM		7/13/2018 3:58 PM
Terminations	Termination Effective Date	Update	Reinstatement	4/1/2018 12:00:00 AM		7/13/2018 3:58 PM
Terminations	Termination Reason	Update	Reinstatement	Failure to recertify		7/13/2018 3:58 PM
Contacts	Authorizing Official	Update		Bliatout, Bobby CEO 5592556476	Bliatout, Bobby CEO Greater Fresno Health Organization Inc 5592556476	7/13/2018 3:49 PM
Contacts	Primary Contact	Update		Bliatout, Bobby CEO 5592556476	Bliatout, Bobby CEO Greater Fresno Health Organization Inc 5592556476	7/13/2018 3:49 PM
Contacts	Signed By	Update		Bliatout, Bobby CEO 5592556476	Bliatout, Bobby CEO Greater Fresno Health Organization Inc 5592556476	7/13/2018 3:49 PM
Details	State	Update		To Be Terminated	Terminated	4/1/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		4/1/2018 12:00:00 AM	3/8/2018 1:33 PM
Details	State	Update	Recertification	Active	To Be Terminated	3/8/2018 1:33 PM
Terminations	Termination Date	Update	Recertification		4/1/2018 12:00:00 AM	3/8/2018 1:33 PM
Terminations	Termination Effective Date	Update	Recertification		4/1/2018 12:00:00 AM	3/8/2018 1:33 PM
Terminations	Termination Reason	Update	Recertification		Failure to recertify	3/8/2018 1:33 PM
Addresses	Main Address	Insert			4011 N Marks Ave Fresno, CA 93722-4555	2/22/2017 5:10 PM
Contacts	Authorizing Official	Insert			Bliatout, Bobby CEO 5592556476	2/22/2017 5:10 PM
Contacts	Primary Contact	Insert			Bliatout, Bobby CEO 5592556476	2/22/2017 5:10 PM
Contacts	Signed By	Insert			Bliatout, Bobby CEO 5592556476	2/22/2017 5:10 PM
Details	Last Recertification Date	Update		3/3/2016 12:00:00 AM	2/22/2017 12:00:00 AM	2/22/2017 5:10 PM
Details	Last Recertification Date	Update		3/5/2015 12:00:00 AM	3/3/2016 12:00:00 AM	3/7/2016 4:17 PM
Details	Last Recertification Date	Update			3/5/2015 12:00:00 AM	3/5/2015 3:14 PM
Dates	Participating Approval Date	Update			7/29/2014 12:00:00 AM	7/29/2014 5:38 PM
Details	State	Update		Pending	Active	7/29/2014 5:38 PM
Dates	Start Date	Update			10/1/2014 12:00:00 AM	7/29/2014 5:38 PM
Details	340B ID	Update		ONLINE_REG_44613	FQHCLA311A	7/29/2014 2:22 PM
Details	340B ID	Update		ONLINE_REG	ONLINE_REG_44613	7/7/2014 4:54 PM
Details	Last Recertification Date	Insert				7/7/2014 4:54 PM
Details	Grant Number	Insert			LAL000041	7/7/2014 4:54 PM
Details	340B ID	Insert			ONLINE_REG	7/7/2014 4:54 PM
Details	Is Authorizing Official EHB Data	Insert			False	7/7/2014 4:54 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/7/2014 4:54 PM
Details	Medicare Provider Number	Insert				7/7/2014 4:54 PM
Details	Entity Name	Insert			Greater Fresno Health Organization	7/7/2014 4:54 PM
Details	Program Code	Insert			FQHCLA	7/7/2014 4:54 PM
Details	Entity Subname	Insert			North Marks Medical Clinic	7/7/2014 4:54 PM
Dates	Participating Approval Date	Insert				7/7/2014 4:54 PM
Details	State	Insert			Pending	7/7/2014 4:54 PM
Dates	Registration Date	Insert			7/7/2014 12:00:00 AM	7/7/2014 4:54 PM
Dates	Signed By Date	Insert			7/7/2014 12:00:00 AM	7/7/2014 4:54 PM
Dates	Start Date	Insert				7/7/2014 4:54 PM
Terminations	Termination Comments	Insert				7/7/2014 4:54 PM
Terminations	Termination Date	Insert				7/7/2014 4:54 PM
Terminations	Termination Effective Date	Insert				7/7/2014 4:54 PM
Terminations	Termination Reason	Insert				7/7/2014 4:54 PM

340B Drug Pricing Program Database