Covered Entity Details

CHC26601-05 Full Circle Health, Inc. (Active) - information as of 4/23/2025 10:51:45 PM

Main Details

Name

Full Circle Health, Inc.

Subdivision Name

Full Circle Health - Raymond

Type

HRSA-Funded Health Center

Site ID

BPS-H80-014128

340B ID

CHC26601-05

Grant Number

H80CS26601

Additional Details

Current Program Status

Active

Registration Date

10/10/2014

Participating Start Date

1/1/2015

Participating Approval Date

10/16/2014

Last Recertification Date

2/13/2025

Contacts

Authorizing Official

Family Medicine Residency of Idaho
Tad Arnt, Chief Operating Officer
(208) 514-2500 Ext: 1104

Primary Contact

Family Medicine Residency of Idaho
Jared L Moore, Director of Pharmacy
(208) 514-2500 Ext: 7040

Addresses

Street Address

777 N Raymond St
Boise, ID 83704-9251

Billing Address

Full Circle Health
6565 W Emerald Street
Boise, ID 83704

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
ID	1710525829,1891047791,1841490075,1669125548,1164267373	1710525829,1841490075,1891047791,1669125548,1164267373
OR	1841490075	1841490075

Shipping Addresses

Shipping Address 1

Full Circle Health
6565 W Emerald Street
Boise, ID 83704

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
CHC26601-00	Active	BPS-H80-013100	Full Circle Health, Inc.	Full Circle Health - Meridian	2275 S Eagle Rd STE 120	Meridian	ID
CHC26601-01	Active	BPS-H80-013204	Full Circle Health, Inc.	Full Circle Health - Kuna	708 E Wythe Creek Ct STE 103	Kuna	ID
CHC26601-02	Terminated	BPS-H80-013174	Full Circle Health, Inc.	Full Circle Health - Meridian Schools Clinic	925 NW 1st St	Meridian	ID
CHC26601-03	Active	BPS-H80-027740	Full Circle Health, Inc.	Full Circle Health - Idaho Street	325 W Idaho St	Boise	ID
CHC26601-04	Active	BPS-H80-018070	Full Circle Health, Inc.	Full Circle Health - Emerald	6565 W Emerald St	Boise	ID
CHC26601-05	Active	BPS-H80-014128	Full Circle Health, Inc.	Full Circle Health - Raymond	777 N Raymond St	Boise	ID
CHC26601-06	Terminated	BPS-H80-016923	FAMILY MEDICINE RESIDENCY OF IDAHO	Family Medicine Health Center-Garden City	215 W 35th St	Garden City	ID
CHC26601-07	Active	BPS-H80-020879	Full Circle Health, Inc.	Full Circle Health - Nampa South	215 East Hawaii Ave Ste 140	Nampa	ID
CHC26601-08	Terminated	BPS-H80-020927	Family Medicine Residency Of Idaho	Family Medicine Health Center – Meridian Pediatrics	3277 E LOUISE DR STE 220	Meridian	ID
CHC26601-09	Terminated	BPS-H80-031706	Family Medicine Residency Of Idaho	Temporary Site - Family Medicine Health Center, Respite Site-Red Lion Hotel, Rooms 301-348	1800 W Fairview Ave Rm 301-348	Boise	ID
CHC26601-10	Terminated	BPS-H80-030683	Family Medicine Residency Of Idaho	Temporary Site-Family Medicine Health Center, Mobile Van	777 N Raymond St	Boise	ID
CHC26601-11	Active	BPS-H80-030892	Full Circle Health, Inc.	Full Circle Health - Nampa North	9850 W St Luke's Drive # 329	Nampa	ID
CHC26601-12	Terminated	BPS-H80-031290	Family Medicine Residency Of Idaho	Family Medicine Health Center, Nampa South Peds	215 E Hawaii Ave Ste 390	Nampa	ID
CHC26601-13	Active	BPS-H80-035836	FULL CIRCLE HEALTH, INC.	Full Circle Health - Boise Pediatrics	8610 W Overland Rd	Boise	ID
CHC26601-14	Active	BPS-H80-036680	FULL CIRCLE HEALTH, INC.	Full Circle Health - Caldwell	315 E Elm St # 201	Caldwell	ID

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CHC26601-00	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/01/2022
CHC26601-00	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/01/2022
CHC26601-00	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/01/2022
CHC26601-00	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	04/01/2022
CHC26601-00	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/01/2022
CHC26601-00	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/01/2022
CHC26601-00	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	04/01/2022
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #126	640 HIGHWAY 16	EMMETT	ID	83617	04/01/2017
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #164	20 EAST FAIRVIEW AVE	MERIDIAN	ID	83642-1732	04/01/2017
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #180	3301 WEST CHERRY LANE	MERIDIAN	ID	83642	04/01/2017	01/27/2022
CHC26601-00	ALBERTSONS LLC	ALBERTSONS PHARMACY #199	1219 S BROADWAY AVE	BOISE	ID	83706	04/01/2017
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #169	909 EAST PARKCENTER BLVD	BOISE	ID	83706	04/01/2017	01/27/2022
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #162	5100 OVERLAND RD	BOISE	ID	83705	04/01/2017
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #166	2500 BLAINE ST	CALDWELL	ID	83605	04/01/2017	01/27/2022
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #101	1650 W. STATE STREET	BOISE	ID	83702	04/01/2017
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #165	528 NORTH MAIN ST	MOUNTAIN HOME	ID	83647	04/01/2017	01/27/2022
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #176	2400 12TH AVENUE RD	NAMPA	ID	83686	04/01/2017
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #154	1520 NORTH COLE RD	BOISE	ID	83704	04/01/2017
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #160	10500 OVERLAND RD	BOISE	ID	83709	04/01/2017
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #156	7100 WEST STATE ST.	BOISE	ID	83714	04/01/2017
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #3337	700 E AVALON ST	KUNA	ID	83634	04/01/2017
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #182	250 SOUTH EAGLE RD	EAGLE	ID	83616	04/01/2017
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #161	10700 USTICK RD	BOISE	ID	83713	04/01/2017
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #189	3614 WEST STATE ST	BOISE	ID	83703	04/01/2017
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #168	405 S MAIN ST	PAYETTE	ID	83661	04/01/2017
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #193	1653 S. VISTA AVE	BOISE	ID	83705	04/01/2017
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #177	4700 NORTH EAGLE RD	BOISE	ID	83713	04/01/2017
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #1602	715 12TH AVE S	NAMPA	ID	83651	01/01/2024
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #169	909 EAST PARKCENTER BLVD	BOISE	ID	83706	01/01/2024
CHC26601-00	ALBERTSONS LLC	SAV-ON PHARMACY #3366	20 E WYOMING AVE	HOMEDALE	ID	83628	01/01/2024
CHC26601-00	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	13925 YALE AVE STE 145		IRVINE	CA	92620-2670	01/01/2024
CHC26601-00	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	01/01/2024
CHC26601-00	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	01/01/2024
CHC26601-00	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	04/01/2023
CHC26601-00	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/01/2023
CHC26601-00	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/01/2023
CHC26601-00	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	04/01/2023
CHC26601-00	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	04/01/2023
CHC26601-00	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/01/2023
CHC26601-00	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	04/01/2023
CHC26601-00	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/01/2023
CHC26601-00	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/01/2023
CHC26601-00	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	04/01/2023
CHC26601-00	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	04/01/2023
CHC26601-00	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	04/01/2023
CHC26601-00	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	04/01/2023
CHC26601-00	CYSTIC FIBROSIS SERVICES	CYSTIC FIBROSIS SERVICES, INC	10530 JOHN W ELLIOTT DR, STE 200	FRISCO	TX	75033	07/01/2015	08/09/2017
CHC26601-00	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	07/01/2017
CHC26601-00	DOGWOOD PHARMACY LLC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER RD STE K	GREENVILLE	SC	29607-6541	01/01/2024
CHC26601-00	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	04/01/2022
CHC26601-00	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	04/01/2022
CHC26601-00	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	04/01/2022
CHC26601-00	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	04/01/2022
CHC26601-00	FRED MEYER	5230 W. FRANKLIN ROAD		BOISE	ID	83705-1109	04/01/2017
CHC26601-00	FRED MEYER	800 YELLOWSTONE AVENUE		POCATELLO	ID	83201-4461	04/01/2017	08/26/2019
CHC26601-00	FRED MEYER	5425 CHINDEN BLVD		GARDEN CITY	ID	83714-1468	04/01/2017
CHC26601-00	FRED MEYER	10751 WEST OVERLAND ROAD		BOISE	ID	83709-1330	04/01/2017
CHC26601-00	FRED MEYER	1850 EAST FAIRVIEW AVENUE		MERIDIAN	ID	83642	04/01/2017
CHC26601-00	FRED MEYER	50 SECOND STREET SOUTH		NAMPA	ID	83651-3700	04/01/2017
CHC26601-00	FRED MEYER PHARMACY #685	1400 WEST CHINDEN BLVD		MERIDIAN	ID	83646	04/01/2017
CHC26601-00	HEALTHY OPTIONS INC	DBA POSTAL PRESCRIPTION SVCS	3500 SE 26TH AVE PO BOX 2718	PORTLAND	OR	97202	04/01/2017
CHC26601-00	IDAHO CVS PHARMACY, L.L.C.	CVS/PHARMACY # 11169	7402 WEST FAIRVIEW AVE	BOISE	ID	83704	04/01/2023
CHC26601-00	IDAHO CVS PHARMACY, L.L.C.	CVS PHARMACY # 17284	16300 N MARKET PLACE BLVD	NAMPA	ID	83687	04/01/2023
CHC26601-00	K MART PHARMACY #3189	1813 CALDWELL BLVD		NAMPA	ID	83651	04/01/2017	08/20/2018
CHC26601-00	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	10/01/2017	04/01/2022
CHC26601-00	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/01/2023
CHC26601-00	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	04/01/2023
CHC26601-00	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	04/01/2023
CHC26601-00	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	04/01/2023
CHC26601-00	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2819	1309 NW 23RD AVE.	PORTLAND	OR	97210	04/01/2023
CHC26601-00	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	01/01/2024
CHC26601-00	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	01/01/2024
CHC26601-00	SANTA BARBARA SPECIALTY PHARMACY LLC	4690 CARPINTERIA AVE STE B		CARPINTERIA	CA	93013	01/01/2024
CHC26601-00	SHOPKO PHARMACY #2064	2100 CALDWELL BLVD		NAMPA	ID	83651-1510	04/01/2017	01/11/2019
CHC26601-00	SHOPKO PHARMACY #2065	8105 W FAIRVIEW AVE		BOISE	ID	83704-8495	04/01/2017	01/11/2019
CHC26601-00	SHOPKO PHARMACY #2095	2655 SOUTH BROADWAY AVE		BOISE	ID	83706	04/01/2017	01/11/2019
CHC26601-00	SMITH'S DRUG KING #86	SMITH'S FOOD KING #1	70 YELLOW CREEK RD	EVANSTON	WY	82930	04/01/2017	08/14/2017
CHC26601-00	THRIFTY PAYLESS, INC.	RITE AID #5413	1515 WEST STATE STREET	BOISE	ID	83702	04/01/2022	02/17/2024
CHC26601-00	THRIFTY PAYLESS, INC.	RITE AID #5400	728 SOUTH WEST 4TH AVENUE	ONTARIO	OR	97914	04/01/2022	02/17/2024
CHC26601-00	THRIFTY PAYLESS, INC.	RITE AID #5417	5005 WEST OVERLAND ROAD	BOISE	ID	83705	04/01/2022	11/09/2023
CHC26601-00	THRIFTY PAYLESS, INC.	RITE AID #5412	1600 NORTH MAIN STREET	MERIDIAN	ID	83642	04/01/2022	09/29/2023
CHC26601-00	THRIFTY PAYLESS, INC.	RITE AID #5415	10600 FAIRVIEW AVENUE	BOISE	ID	83713	04/01/2022	01/18/2024
CHC26601-00	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	10/01/2017	11/17/2018
CHC26601-00	WAL-MART PHARMACY 10-1995	4240 YELLOWSTONE AVENUE		CHUBBUCK	ID	83202	04/01/2017	11/17/2018
CHC26601-00	WAL-MART PHARMACY 10-2508	8300 WEST OVERLAND ROAD		BOISE	ID	83709	04/01/2017	11/17/2018
CHC26601-00	WAL-MART PHARMACY 10-2861	7319 WEST STATE STREET	PO BOX 1407	GARDEN CITY	ID	83714	04/01/2017	11/17/2018
CHC26601-00	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	10/01/2017	11/17/2018
CHC26601-00	WALGREEN CO	DBA: WALGREENS #10604	1625 S MERIDIAN RD	MERIDIAN	ID	83642-6002	07/01/2015
CHC26601-00	WALGREEN CO	DBA: WALGREENS #10672	2219 12TH AVE RD	NAMPA	ID	83686-6313	07/01/2015
CHC26601-00	WALGREEN CO	DBA: WALGREENS #11541	4110 S. 10TH AVENUE	CALDWELL	ID	83605	07/01/2015
CHC26601-00	WALGREEN CO	DBA: WALGREENS #12123	3395 S. FEDERAL WAY	BOISE	ID	83705	07/01/2015	02/27/2024
CHC26601-00	WALGREEN CO	DBA: WALGREENS #11452	3263 N EAGLE RD	MERIDIAN	ID	83646	07/01/2024
CHC26601-00	WALGREEN CO.	DBA: WALGREENS # 01221	3212 E CHINDEN BLVD	EAGLE	ID	83616	07/01/2015	02/21/2018
CHC26601-00	WALGREEN CO.	DBA: WALGREENS # 01972	6725 N GLENWOOD ST	BOISE	ID	83714	07/01/2015
CHC26601-00	WALGREEN CO.	DBA: WALGREENS # 04942	8100 W FAIRVIEW AVE.	BOISE	ID	83704	07/01/2015
CHC26601-00	WALGREEN CO.	DBA: WALGREENS # 05184	10580 W USTICK RD	BOISE	ID	83704	07/01/2015
CHC26601-00	WALGREEN CO.	DBA: WALGREENS # 05185	4924 OVERLAND RD	BOISE	ID	83705	07/01/2015
CHC26601-00	WALGREEN CO.	DBA: WALGREENS # 05565	10555 W OVERLAND RD	BOISE	ID	83709	07/01/2015
CHC26601-00	WALGREEN CO.	DBA: WALGREENS # 05648	700 12TH AVENUE S	NAMPA	ID	83651	07/01/2015
CHC26601-00	WALGREEN CO.	DBA: WALGREENS # 06200	1570 E FAIRVIEW AVE	MERIDIAN	ID	83642	07/01/2015
CHC26601-00	WALGREEN CO.	DBA: WALGREENS # 07276	1012 CLEVELAND BLVD	CALDWELL	ID	83605-3852	07/01/2015
CHC26601-00	WALGREEN CO.	DBA: WALGREENS # 10197	3150 W CHERRY LANE	MERIDIAN	ID	83642-1122	07/01/2015
CHC26601-00	WALGREEN CO.	DBA: WALGREENS #11083	6195 S FIVE MILE	BOISE	ID	83709	07/01/2015
CHC26601-00	WALGREEN CO.	DBA; WALGREENS #13614	869 E AVALON ST	KUNA	ID	83634	07/01/2015
CHC26601-00	WALGREEN CO.	DBA: WALGREENS #13888	455 S. BROADWAY AVE.	BOISE	ID	83702	07/01/2015
CHC26601-00	WALGREEN CO.	DBA: WALGREENS #12483	932 CALDWELL BLVD	NAMPA	ID	83651	01/01/2024
CHC26601-00	WALGREEN CO.	DBA: WALGREENS #11687	4850 N LINDER RD	MERIDIAN	ID	83646	01/01/2024
CHC26601-00	WALGREEN CO.	DBA: WALGREENS # 06971	2285 S APPLE STREET	BOISE	ID	83706-6731	01/01/2025
CHC26601-00	Walgreens #21435	Walgreens Central Fill #21435	6306 S Airport Rd	West Jordan	UT	84084-5601	07/01/2024
CHC26601-00	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	07/01/2015
CHC26601-00	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	07/01/2015	11/04/2021
CHC26601-00	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/01/2015
CHC26601-00	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	07/01/2015

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/13/2025 5:14 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1164267373	2/13/2025 5:14 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		ID	2/13/2025 5:14 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1164267373	2/13/2025 5:14 PM
Medicaid Billing	NPI: State	Insert	Recertification		ID	2/13/2025 5:14 PM
Details	Last Recertification Date	Update	Recertification	2/8/2024 4:15:27 PM	2/13/2025 5:14:29 PM	2/13/2025 5:14 PM
Details	Last Recertification Date	Update	Recertification	2/14/2023 7:52:37 AM	2/8/2024 4:15:27 PM	2/8/2024 4:15 PM
Addresses	Billing Address	Insert	Recertification		Full Circle Health 6565 W Emerald Street Boise, ID 83704	2/14/2023 7:52 AM
Addresses	Shipping Address	Insert	Recertification		Full Circle Health 6565 W Emerald Street Boise, ID 83704	2/14/2023 7:52 AM
Details	Last Recertification Date	Update	Recertification	2/4/2022 10:07:47 AM	2/14/2023 7:52:37 AM	2/14/2023 7:52 AM
Details	Entity Subname	Update	Recertification	Family Medicine Health Center-Raymond	Full Circle Health - Raymond	2/14/2023 7:52 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/30/2022 3:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1669125548	11/30/2022 3:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	11/30/2022 3:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1669125548	11/30/2022 3:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	11/30/2022 3:12 PM
Details	Entity Name	Update	Group Change Request	Family Medicine Residency Of Idaho	Full Circle Health, Inc.	9/12/2022 1:45 PM
Contacts	Primary Contact	Update	Group Change Request	Robin, Michelle Sr. Director, Grant Compliance Family Medicine Residency of Idaho, Inc. (The) 2088607299	Moore, Jared L Director of Pharmacy Family Medicine Residency of Idaho 2085142500-7040	6/30/2022 10:25 AM
Details	Last Recertification Date	Update	Recertification	2/11/2021 10:51:25 AM	2/4/2022 10:07:47 AM	2/4/2022 10:07 AM
Contacts	Authorizing Official	Update	Group Change Request	Allen, Sabrina Sr. Director of Pharmacy Services Family Medicine Residency of Idaho, Inc. (The) 2085142500-7040	Arnt, Tad Chief Operating Officer Family Medicine Residency of Idaho 2085142500-1104	9/1/2021 2:10 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1891047791 ( )		2/11/2021 10:51 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1841490075 ( )		2/11/2021 10:51 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1710525829	2/11/2021 10:51 AM
Medicaid Billing	NPI: State	Insert	Recertification		ID	2/11/2021 10:51 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841490075	2/11/2021 10:51 AM
Medicaid Billing	NPI: State	Insert	Recertification		ID	2/11/2021 10:51 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1891047791	2/11/2021 10:51 AM
Medicaid Billing	NPI: State	Insert	Recertification		ID	2/11/2021 10:51 AM
Details	Last Recertification Date	Update	Recertification	2/3/2020 11:03:20 AM	2/11/2021 10:51:25 AM	2/11/2021 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/10/2020 4:53 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841490075	8/10/2020 4:53 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	8/10/2020 4:53 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1841490075	8/10/2020 4:53 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	8/10/2020 4:53 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/1/2020 5:52 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1710525829	4/1/2020 5:52 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	4/1/2020 5:52 PM
Details	Last Recertification Date	Update	Recertification	2/14/2019 12:21:57 PM	2/3/2020 11:03:20 AM	2/3/2020 11:03 AM
Contacts	Primary Contact	Update	Change Request	Sherwood, Heather 340B Analyst Family Medicine Residency of Idaho, Inc. (The) 2085142500-7042	Robin, Michelle Sr. Director, Grant Compliance Family Medicine Residency of Idaho, Inc. (The) 2088607299	6/3/2019 6:30 AM
Contacts	Authorizing Official	Update	Profile Change Request	Allen, Sabrina Pharmacy Director Family Medicine Residency of Idaho, Inc. (The) 2085142500-7040	Allen, Sabrina Sr. Director of Pharmacy Services Family Medicine Residency of Idaho, Inc. (The) 2085142500-7040	5/30/2019 4:50 PM
Details	Last Recertification Date	Update	Recertification	2/20/2018 1:35:57 PM	2/14/2019 12:21:57 PM	2/14/2019 12:21 PM
Contacts	Authorizing Official	Update	Change Request	Epperly, Ted President and CEO Family Medicine Residency of Idaho INC 2089548744	Allen, Sabrina Pharmacy Director Family Medicine Residency of Idaho, Inc. (The) 2085142500-7040	8/31/2018 8:53 AM
Contacts	Primary Contact	Update	Change Request	Allen, Sabrina Pharmacy Director Family Medicine Residency of Idaho, Inc. (The) 2085142500-7040	Sherwood, Heather 340B Analyst Family Medicine Residency of Idaho, Inc. (The) 2085142500-7042	8/31/2018 8:53 AM
Details	Is Authorizing Official EHB Data	Update	Change Request	False		8/31/2018 8:53 AM
Details	Last Recertification Date	Update	Recertification	1/26/2017 12:00:00 AM	2/20/2018 1:35:57 PM	2/20/2018 1:35 PM
Contacts	Authorizing Official	Update		Epperly, Ted President and CEO 2089548744	Epperly, Ted President and CEO Family Medicine Residency of Idaho INC 2089548744	11/16/2017 2:43 PM
Contacts	Primary Contact	Update		Allen, Sabrina Pharmacy Director 2085142500-7040	Allen, Sabrina Pharmacy Director Family Medicine Residency of Idaho, Inc. (The) 2085142500-7040	9/25/2017 5:38 PM
Contacts	Authorizing Official	Insert			Epperly, Ted President and CEO 2089548744	8/14/2017 6:02 PM
Contacts	Primary Contact	Insert			Allen, Sabrina Pharmacy Director 2085142500-7040	2/13/2017 6:42 AM
Contacts	Signed By	Insert			Bevans, Steve CFO/COO 2089548680	2/13/2017 6:42 AM
Addresses	Main Address	Insert			777 N Raymond St Boise, ID 83704-9251	1/26/2017 12:10 PM
Details	Last Recertification Date	Update		2/26/2016 12:00:00 AM	1/26/2017 12:00:00 AM	1/26/2017 12:10 PM
Details	Last Recertification Date	Update		2/11/2015 12:00:00 AM	2/26/2016 12:00:00 AM	2/26/2016 11:26 AM
Details	Last Recertification Date	Update			2/11/2015 12:00:00 AM	2/11/2015 11:13 AM
Dates	Participating Approval Date	Update			10/16/2014 12:00:00 AM	10/16/2014 4:58 PM
Details	State	Update		Pending	Active	10/16/2014 4:58 PM
Dates	Start Date	Update			1/1/2015 12:00:00 AM	10/16/2014 4:58 PM
Details	340B ID	Update		ONLINE_REG_46985	CHC26601-05	10/10/2014 1:35 PM
Details	340B ID	Update		ONLINE_REG	ONLINE_REG_46985	10/10/2014 12:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/10/2014 12:10 PM
Medicaid Billing	Medicaid: Number	Insert			1891047791	10/10/2014 12:10 PM
Medicaid Billing	Medicaid: State	Insert			ID	10/10/2014 12:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/10/2014 12:10 PM
Medicaid Billing	Medicaid: Number	Insert			1841490075	10/10/2014 12:10 PM
Medicaid Billing	Medicaid: State	Insert			ID	10/10/2014 12:10 PM
Medicaid Billing	NPI: Number	Insert			1891047791	10/10/2014 12:10 PM
Medicaid Billing	NPI: Number	Insert			1841490075	10/10/2014 12:10 PM
Details	Last Recertification Date	Insert				10/10/2014 12:10 PM
Details	Grant Number	Insert			H80CS26601	10/10/2014 12:10 PM
Details	340B ID	Insert			ONLINE_REG	10/10/2014 12:10 PM
Details	Is Authorizing Official EHB Data	Insert			False	10/10/2014 12:10 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/10/2014 12:10 PM
Details	Medicare Provider Number	Insert				10/10/2014 12:10 PM
Details	Entity Name	Insert			Family Medicine Residency Of Idaho	10/10/2014 12:10 PM
Details	Program Code	Insert			CH	10/10/2014 12:10 PM
Details	Entity Subname	Insert			Family Medicine Health Center-Raymond	10/10/2014 12:10 PM
Dates	Participating Approval Date	Insert				10/10/2014 12:10 PM
Details	State	Insert			Pending	10/10/2014 12:10 PM
Dates	Registration Date	Insert			10/10/2014 12:00:00 AM	10/10/2014 12:10 PM
Dates	Signed By Date	Insert			10/10/2014 12:00:00 AM	10/10/2014 12:10 PM
Dates	Start Date	Insert				10/10/2014 12:10 PM
Terminations	Termination Comments	Insert				10/10/2014 12:10 PM
Terminations	Termination Date	Insert				10/10/2014 12:10 PM
Terminations	Termination Effective Date	Insert				10/10/2014 12:10 PM
Terminations	Termination Reason	Insert				10/10/2014 12:10 PM

340B Drug Pricing Program Database