Covered Entity Details

CH09039AY CLINICA SIERRA VISTA (Active) - information as of 5/3/2025 11:30:05 PM

Main Details

Name

CLINICA SIERRA VISTA

Subdivision Name

CLINICA SIERRA VISTA - Kern Mobile Unit

Type

HRSA-Funded Health Center

Site ID

BPS-H80-017133

340B ID

CH09039AY

Grant Number

H80CS00540

Additional Details

Current Program Status

Active

Registration Date

1/6/2016

Participating Start Date

4/1/2016

Participating Approval Date

2/16/2016

Last Recertification Date

3/3/2025

Contacts

Authorizing Official

Clinica Sierra Vista
Dixit Bhakta, Director of Pharmacy
(661) 779-3118

Primary Contact

Clinica Sierra Vista
Diane Marin-Gonzalez, 340B Analyst
(954) 686-5823

Addresses

Street Address

301 Brundage Ln
Bakersfield, CA 93304

Billing Address

Clinica Sierra Vista
1430 Truxtun Ave, STE 400
PO BOX 1559
Bakersfield, CA 93301

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		1336544790,1144897505,1245008598,1508634858,1275161325,1316575467

Shipping Addresses

Same as Street Address

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
CH090390	Active	BPS-H80-003177	CLINICA SIERRA VISTA	CORPORATE HQ - CLINICA SIERRA VISTA	1430 Truxtun Ave STE 400	Bakersfield	CA
CH09039A	Active	BPS-H80-004082	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - McFarland Community Health Center	217 W Kern Ave	Mc Farland	CA
CH09039AA	Active	BPS-H80-012397	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - Elm Women's & Pediatric Health Center	2760 S Elm Ave	FRESNO	CA
CH09039AB	Terminated	BPS-H80-011507	CLINICA SIERRA VISTA	Garland Community Health Center	3727 N 1st St STE 106	Fresno	CA
CH09039AC	Active	BPS-H80-005467	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - Regional Medical Community Health Center	2505 E Divisadero St	FRESNO	CA
CH09039AD	Active	BPS-H80-002235	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - West Fresno Community Health Center	302 Fresno St STE 101	Fresno	CA
CH09039AE	Active	BPS-H80-010857	CLINICA SIERRA VISTA	DENTAL: CLINICA SIERRA VISTA - East Bakersfield Dental Center	1125 E California Ave	Bakersfield	CA
CH09039AF	Terminated	BPS-H80-002235	CLINICA SIERRA VISTA	WEST FRESNO COMMUNITY HEALTH CENTER	302 Fresno St	Fresno	CA
CH09039AG	Active	BPS-H80-004096	CLINICA SIERRA VISTA	DENTAL: CLINICA SIERRA VISTA - West Delano Dental Center	441 Diaz Ave	Delano	CA
CH09039AH	Terminated	BPS-H80-003076	CLINICA SIERRA VISTA	DEATH VALLEY HEALTH CENTER	140 N. State Highway 127	SHOSHONE	CA
CH09039AI	Active	BPS-H80-021277	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - West Shaw Community Health Center	3645 W Shaw Ave Ste 101	Fresno	CA
CH09039AJ	Active	BPS-H80-011079	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - Family Health Center	1611 1st street	Bakersfield	CA
CH09039AK	Active	BPS-H80-010017	CLINICA SIERRA VISTA	DENTAL: CLINICA SIERRA VISTA - Elm Dental Center	2756 S. Elm Ave	Fresno	CA
CH09039AL	Active	BPS-H80-012415	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - North Fine Community Health Center	1945 N Fine Ave STE 100	Fresno	CA
CH09039AM	Terminated	BPS-H80-003959	CLINICA SIERRA VISTA	Old Town Kern Community Health Center	234 Baker St STE 1 & 2	Bakersfield	CA
CH09039AN	Active	BPS-H80-012638	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - Greenfield Community Health Center	9001 South H Street	Bakersfield	CA
CH09039AP	Terminated	BPS-H80-005593	CLINICA SIERRA VISTA	DELANO ADULT BEHAVIORAL HLTH SVC	828 High St STE C	Delano	CA
CH09039AQ	Terminated	BPS-H80-017817	CLINICA SIERRA VISTA	SOUTH CENTRAL BAKERSFIELD BHC	3105 Wilson Road	Bakersfield	CA
CH09039AR	Terminated	BPS-H80-001259	CLINICA SIERRA VISTA	LAMONT CHILDREN'S BEHAVIORAL HEALTH SERVICES	7839 Burgundy Ave	Lamont	CA
CH09039AS	Terminated	BPS-H80-000302	CLINICA SIERRA VISTA	FRAZIER PARK BEHAVIORAL HLTH SVC	3717 MT PINOS WAY STE C& D	FRAZIER PARK	CA
CH09039AT	Terminated	BPS-H80-000675	CLINICA SIERRA VISTA	LAMONT ADULT BEHAVIORAL HLTH SVC	8787 Hall Rd	Lamont	CA
CH09039AU	Terminated	BPS-H80-008703	CLINICA SIERRA VISTA	Arvin Dental Center	1305 Bear Mountain Blvd., Suite B	Arvin	CA
CH09039AV	Active	BPS-H80-013069	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - East Niles Community Health Center	7800 Niles St	Bakersfield	CA
CH09039AW	Active	BPS-H80-013783	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - Gaston Middle School Health and Wellness Center	1120 E CHURCH AVE	FRESNO	CA
CH09039AX	Terminated	BPS-H80-017253	CLINICA SIERRA VISTA	Fresno Mobile Unit	4498 N. Brawley Avenue	Fresno	CA
CH09039AY	Active	BPS-H80-017133	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - Kern Mobile Unit	301 Brundage Ln	Bakersfield	CA
CH09039AZ	Active	BPS-H80-015627	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - Baker Street Village Community Health Center	1015 Baker St # 4	Bakersfield	CA
CH09039B	Active	BPS-H80-005542	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - Frazier Mountain Community Health Center	704 LEBEC ROAD	LEBEC	CA
CH09039BA	Terminated	BPS-H80-018772	Clinica Sierra Vista	Baker-Death Valley Health Center	72730-C Baker Blvd	Baker	CA
CH09039BB	Terminated	BPS-H80-021400	Clinica Sierra Vista	Millbrook Community Health Center	7202 N Millbrook Ave Ste 202	Fresno	CA
CH09039BC	Active	BPS-H80-030033	Clinica Sierra Vista	CLINICA SIERRA VISTA - Addams Elementary School Health and Wellness Center	1510 N Lafayette Ave	Fresno	CA
CH09039BD	Active	BPS-H80-030193	Clinica Sierra Vista	CLINICA SIERRA VISTA - Delano Walk In Clinic	425 Del Sol Pkwy	Delano	CA
CH09039BE	Active	BPS-H80-034013	Clinica Sierra Vista	Clinica Sierra Vista - Comprehensive Care Center	625 34th Street STE 100, 200	Bakersfield	CA
CH09039BF	Active	BPS-H80-036268	CLINICA SIERRA VISTA	Blackstone CHC	1685 East Home Ave.	Fresno	CA
CH09039BG	Active	BPS-H80-001198	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - Fresno Administrative Office	1945 N Fine Ave STE 116	Fresno	CA
CH09039BH	Active	BPS-H80-037625	CLINICA SIERRA VISTA	Fresno Mobile Unit	1945 N Fine Ave, Ste 108	Fresno	CA
CH09039C	Active	BPS-H80-002513	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - Kern River Health Center	67 Evans Rd	Wofford Heights	CA
CH09039D	Active	BPS-H80-001823	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - East Bakersfield Community Health Center	815 DR. MARTIN LUTHER KING JR BLVD	BAKERSFIELD	CA
CH09039E	Active	BPS-H80-001535	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - Delano Community Health Center	1508 GARCES HWY STE 1	DELANO	CA
CH09039F	Active	BPS-H80-004247	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - Central Bakersfield Community Health Center	301 Brundage Ln	Bakersfield	CA
CH09039H	Active	BPS-H80-003897	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - Arvin Community Health Center	1305 Bear Mountain Blvd	Arvin	CA
CH09039J	Active	BPS-H80-003407	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - Lamont Community Health Center	8787 Hall Rd	Lamont	CA
CH09039K	Terminated	BPS-H80-003919	CLINICA SIERRA VISTA	KERN VALLEY MEDICAL CENTER	6310 Lake Isabella Blvd	Lake Isabella	CA
CH09039M	Active	BPS-H80-011283	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - 34th Street Community Health Center	2000 Physicians Blvd	Bakersfield	CA
CH09039N	Active	BPS-H80-002988	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - South Bakersfield Community Health Center	2400 Wible Rd STE 14	Bakersfield	CA
CH09039V	Terminated	bps-h80-001249	CLINICA SIERRA VISTA	NORTH OF THE RIVER COMM HLTH CTR	2525 N Chester Ave	Bakersfield	CA
CH09039W	Terminated	BPS-H80-001320	CLINICA SIERRA VISTA	Divisadero Community Health Center	145 N. CLARK	FRESNO	CA
CH09039X	Terminated	BPS-H80-003983	CLINICA SIERRA VISTA	EASTON COMMUNITY HEALTH CENTER	5784 S ELM AVE	FRESNO	CA
CH09039Y	Active	BPS-H80-012399	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - Elm Community Health Center	2740 S Elm Ave	Fresno	CA
CH09039Z	Active	BPS-H80-001080	CLINICA SIERRA VISTA	CLINICA SIERRA VISTA - Orange and Butler Community Health Center	1350 S Orange Ave	Fresno	CA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH090390	ALBERTSONS LLC	SAV-ON PHARMACY #0336	1520 BRUNDAGE LANE	BAKERSFIELD	CA	93304	04/01/2019
CH09039F	ALBERTSONS LLC	SAV-ON PHARMACY #0336	1520 BRUNDAGE LANE	BAKERSFIELD	CA	93304	10/01/2024
CH090390	ARVIN PHARMACY	1241 BEAR MOUNTAIN BLVD	SUITE E	ARVIN	CA	93203	01/01/2019
CH09039H	ARVIN PHARMACY	1241 BEAR MOUNTAIN BLVD	SUITE E	ARVIN	CA	93203	07/01/2024
CH090390	AUROMIRA CORPORATION	DBA: DIMAS PHARMACY	3805 SAN DIMAS ST STE A	BAKERSFIELD	CA	93301	10/01/2021
CH090390	AVITA PHARMACY 1015	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	2000 PHYSICIANS BLVD RM B	BAKERSFIELD	CA	93301-1277	04/01/2020
CH09039M	AVITA PHARMACY 1015	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	2000 PHYSICIANS BLVD RM B	BAKERSFIELD	CA	93301-1277	07/01/2024
CH090390	AVITA PHARMACY 1016	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	8787 HALL RD RM A	LAMONT	CA	93241-1953	07/01/2020	01/13/2025
CH09039J	AVITA PHARMACY 1016	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	8787 HALL RD RM A	LAMONT	CA	93241-1953	07/01/2024	01/13/2025
CH090390	AVITA PHARMACY 1017	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	2400 WIBLE ROAD, ROOM 1	BAKERSFIELD	CA	93304	07/01/2020	02/01/2022
CH090390	AVITA PHARMACY 1018	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	2740 S ELM AVE RM 2	FRESNO	CA	93706-5435	07/01/2020	02/10/2025
CH09039Y	AVITA PHARMACY 1018	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	2740 S ELM AVE RM 2	FRESNO	CA	93706-5435	07/01/2024	02/10/2025
CH090390	AVITA PHARMACY 1024	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	330 E LAMBERT RD STE 120	BREA	CA	92821-4100	04/01/2020
CH090390	AVITA PHARMACY 1025	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	3020 SATURN ST STE 100	BREA	CA	92821	04/01/2020
CH090390	AVITA PHARMACY 1040	AVITA DRUGS, LLC D/B/A AVITA PHARMACY 10	6100 CORPORATE BLVD STE 250	BATON ROUGE	LA	70808	01/01/2021
CH090390	CAREPHARM PHARMACY	4700 PANAMA LN UNIT 116		BAKERSFIELD	CA	93313-3481	01/01/2019
CH09039AN	CAREPHARM PHARMACY	4700 PANAMA LN UNIT 116		BAKERSFIELD	CA	93313-3481	10/01/2024
CH090390	CAREPLUS DRUGS	4177 W SHAW AVE STE 109		FRESNO	CA	93722-6221	04/01/2019	10/09/2020
CH090390	CLINICA PHARMACY	OMGANESH CORPORATION	355 DOVER PKWY STE C	DELANO	CA	93215	10/01/2021
CH09039BD	CLINICA PHARMACY	OMGANESH CORPORATION	355 DOVER PKWY STE C	DELANO	CA	93215	10/01/2024
CH090390	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	10/01/2021
CH090390	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	10/01/2021
CH090390	DELANO FAMILY PHARMACY	1401 GARCES HWY BLDG A		DELANO	CA	93215-3699	01/01/2019	10/15/2021
CH090390	EL TEJON DRUG CO. DBA EL TEJON PHARMACY	3544 MOUNT PINOS WAY		FRAZIER PARK	CA	93225	01/01/2019	05/13/2024
CH090390	EL TEJON DRUGS	2900 BRUNDAGE LN		BAKERSFIELD	CA	93304-2430	01/01/2019	05/13/2024
CH090390	EL TEJON DRUGS	2819 N CHESTER AVE		BAKERSFIELD	CA	93308	01/01/2019	05/13/2024
CH090390	EL TEJON PHARMACY 1	2900 BRUNDAGE LN		BAKERSFIELD	CA	93304	04/01/2025
CH09039AJ	EL TEJON PHARMACY 1	2900 BRUNDAGE LN		BAKERSFIELD	CA	93304	04/01/2025
CH090390	EL TEJON PHARMACY 2	2819 N CHESTER AVE		BAKERSFIELD	CA	93308	04/01/2025
CH090390	EL TEJON PHARMACY 3	3544 MOUNT PINOS WAY		FRAZIER PARK	CA	93225	04/01/2025
CH09039B	EL TEJON PHARMACY 3	3544 MOUNT PINOS WAY		FRAZIER PARK	CA	93225	04/01/2025
CH090390	FAMILY PHARMACY	FAMILY PHARMACY	309 N CHESTER AVE	BAKERSFIELD	CA	93308	01/01/2019	05/27/2019
CH090390	FOX DRUG STORE	7355 N. PALM AVE. STE 100		FRESNO	CA	93711	01/01/2019	06/16/2023
CH090390	FOX DRUG STORE	1939 HIGH ST		SELMA	CA	93662-3510	01/01/2019	01/12/2023
CH090390	FOX DRUG STORE INC.	3020 SAN ANTONIO DR.		FOWLER	CA	93625	01/01/2019	01/02/2019
CH090390	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 06772	4987 N. FRESNO ST.	FRESNO	CA	93726	07/01/2019
CH090390	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY # 10810	505 BEAR MOUNTAIN BLVD, SUITE B	ARVIN	CA	93203	07/01/2019
CH090390	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10921	6601 STINE ROAD	BAKERSFIELD	CA	93313	07/01/2019
CH090390	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16136	900 SHAW AVE	CLOVIS	CA	93612	07/01/2019
CH090390	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16084	3150 W SHAW AVE	FRESNO	CA	93711	07/01/2019
CH090390	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 05422	5180 E. KINGS CANYON ROAD	FRESNO	CA	93727	07/01/2019
CH090390	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16108	3173 E SHIELDS AVE	FRESNO	CA	93726	07/01/2019
CH090390	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 02768	6500 S. UNION AVE.	BAKERSFIELD	CA	93307	07/01/2019
CH090390	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 07001	6500 NILES STREET	BAKERSFIELD	CA	93306	07/01/2019
CH090390	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17552	2901 MING AVE	BAKERSFIELD	CA	93304	07/01/2019
CH090390	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10074	5995 EAST KINGS CANYON RD	FRESNO	CA	93727	07/01/2019
CH090390	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY # 10813	8929 PANAMA RD SUITE B	LAMONT	CA	93241	07/01/2019	08/10/2022
CH090390	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 05495	5184 STOCKDALE HWY.	BAKERSFIELD	CA	93309	07/01/2019
CH090390	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08913	9628 ROSEDALE HWY.	BAKERSFIELD	CA	93312	10/01/2020	07/15/2024
CH090390	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16160	3401 MALL VIEW RD	BAKERSFIELD	CA	93306	10/01/2020
CH090390	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16413	7505 LAGUNA BLVD	ELK GROVE	CA	95758	10/01/2021
CH090390	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09785	2006 WEST AVENUE J	LANCASTER	CA	93536	10/01/2021
CH090390	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16928	4247 S MOONEY BLVD	VISALIA	CA	93277	10/01/2021
CH090390	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY # 4221	11300 MING AVE	BAKERSFIELD	CA	93311	10/01/2021
CH090390	INGRAM'S PHARMACY, LLC	INGRAM'S PHARMACY, LLC	1703 27TH ST	BAKERSFIELD	CA	93301	01/01/2019	09/19/2019
CH090390	INTEGRATED CARE SYSTEMS	7140 W. PERSHING CT		VISALIA	CA	93291-7941	01/01/2019	05/13/2024
CH090390	KAVISH PRAJAPATI INC.	DBA WIBLE PHARMACY	3045 WILSON RD	BAKERSFIELD	CA	93304	01/01/2023
CH09039N	KAVISH PRAJAPATI INC.	DBA WIBLE PHARMACY	3045 WILSON RD	BAKERSFIELD	CA	93304	07/01/2024
CH090390	KOMOTO MEDICAL PHARMACY	2110 TRUXTUN AVE	SUITE 100	BAKERSFIELD	CA	93301	01/01/2019
CH090390	KOMOTO PHARMACY	KOMOTO PHARMACY	1017 ELLINGTON ST	DELANO	CA	93215-2621	01/01/2019
CH09039E	KOMOTO PHARMACY	KOMOTO PHARMACY	1017 ELLINGTON ST	DELANO	CA	93215-2621	10/01/2024
CH090390	LEE'S NILES DRUG STORE	1405 NILES ST		BAKERSFIELD	CA	93305	04/01/2019
CH090390	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09129	1302 FULTON MALL	FRESNO	CA	93721	07/01/2019	09/13/2022
CH090390	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09801	10 SHAW AVE	CLOVIS	CA	93612	07/01/2019
CH090390	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09900	2690 MOUNT VERNON AVE	BAKERSFIELD	CA	93306	07/01/2019
CH090390	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09537	1325 W SHIELDS AVENUE	FRESNO	CA	93705	07/01/2019
CH090390	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09846	6800 N MILBURN AVE	FRESNO	CA	93722	07/01/2019
CH090390	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09204	3500 STINE RD	BAKERSFIELD	CA	93309	07/01/2019	09/27/2023
CH090390	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09971	4077 W CLINTON AVE	FRESNO	CA	93722	07/01/2019	09/20/2023
CH090390	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 07553	3011 E SHIELDS AVE	FRESNO	CA	93726	07/01/2019
CH090390	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 07910	1794 ASHLAN AVE	CLOVIS	CA	93611	10/01/2020
CH090390	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09149	6750 N CEDAR AVE	FRESNO	CA	93710	10/01/2020
CH090390	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09933	1405 HERNDON AVENUE	CLOVIS	CA	93611	10/01/2021
CH090390	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09377	1065 W MANNING AVE	REEDLEY	CA	93654	10/01/2021
CH090390	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09986	1400 HOWARD RD	MADERA	CA	93637	10/01/2021
CH090390	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09983	929 SIERRA ST	KINGSBURG	CA	93631	10/01/2021
CH090390	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09191	5019 S MCCARRAN BLVD	RENO	NV	89502	10/01/2021
CH090390	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09893	2539 N 11TH AVE	HANFORD	CA	93230	10/01/2021
CH090390	LONGS DRUGS OF LEXINGTON	D/B/A AVITA PHARMACY 1051	1216 W MAIN ST STE D	LEXINGTON	SC	29072-2453	01/01/2021
CH090390	MCFARLAND PHARMACY	MCFARLAND HEALTHCARE INC	201 W PERKINS AVE UNIT A	MC FARLAND	CA	93250	04/01/2025
CH09039A	MCFARLAND PHARMACY	MCFARLAND HEALTHCARE INC	201 W PERKINS AVE UNIT A	MC FARLAND	CA	93250	04/01/2025
CH090390	MING & H DRUGS	1717 MING AVE		BAKERSFIELD	CA	93304	10/01/2020
CH090390	NEW LEAF PHARMACY	4433 MING AVE		BAKERSFIELD	CA	93309	01/01/2019	11/30/2019
CH090390	PEOPLE'S PHARMACY	5913 NILES ST STE 2		BAKERSFIELD	CA	93306-7407	01/01/2019
CH090390	PEOPLE'S PHARMACY # 3	4813 COFFEE RD STE 300		BAKERSFIELD	CA	93308	01/01/2022	05/13/2024
CH090390	PHARMEDQUEST PHARMACY	PHARMEDQUEST PHARMACY SERVICES	451 W. LAMBERT RD STE 209	BREA	CA	92821-9282	04/01/2020
CH090390	SAVE MART PHARMACY #651	5750 N FIRST ST		FRESNO	CA	93710-6204	04/01/2019	10/15/2021
CH090390	SAVE MART PHARMACY #93	6797 N. MILBURN		FRESNO	CA	93722-2132	04/01/2019	10/15/2021
CH090390	SHIVOM CORPORATION	DBA: MING PLAZA PHARMACY	2726 MING AVE STE A	BAKERSFIELD	CA	93304	01/01/2023
CH090390	SILVER SPRAY PHARMACY INC	2191 NILES ST		BAKERSFIELD	CA	93305-5168	01/01/2019
CH090390	THE MEDICINE SHOPPE	2484 EAST GETTYSBURG AVENUE		FRESNO	CA	93726-0389	01/01/2019	10/15/2021
CH090390	THRIFTY PAYLESS INC	RITE AID #6768	150 W KERN AVE	MC FARLAND	CA	93250	07/01/2020
CH090390	THRIFTY PAYLESS, INC.	RITE AID #5794	1809 CECIL AVENUE	DELANO	CA	93215	07/01/2020
CH090390	THRIFTY PAYLESS, INC.	RITE AID #5797	5530 LAKE ISABELLA BOULEVARD PO BOX 3740	LAKE ISABELLA	CA	93240	07/01/2020
CH090390	THRIFTY PAYLESS, INC.	RITE AID #5862	1210 NORTH BLACKSTONE AVENUE	FRESNO	CA	93703	07/01/2020
CH090390	THRIFTY PAYLESS, INC.	RITE AID #6791	431 34TH ST	BAKERSFIELD	CA	93301-2236	07/01/2020
CH090390	THRIFTY PAYLESS, INC.	RITE AID #5814	2505 MT VERNON AVENUE	BAKERSFIELD	CA	93306	07/01/2020
CH090390	THRIFTY PAYLESS, INC.	RITE AID #5815	100 CHINA GRADE LOOP	BAKERSFIELD	CA	93308	07/01/2020
CH090390	THRIFTY PAYLESS, INC.	RITE AID #5861	4224 EAST SHIELDS AVENUE	FRESNO	CA	93726	07/01/2020	03/12/2024
CH090390	THRIFTY PAYLESS, INC.	RITE AID #6295	1101 FRESNO STREET	FRESNO	CA	93706	07/01/2020
CH090390	THRIFTY PAYLESS, INC.	RITE AID #5809	1601 23RD STREET	BAKERSFIELD	CA	93301	07/01/2020
CH090390	THRIFTY PAYLESS, INC.	RITE AID #6289	4593 NORTH CEDAR AVENUE	FRESNO	CA	93726	07/01/2020
CH090390	THRIFTY PAYLESS, INC.	RITE AID #5872	5574 EAST KINGS CANYON	FRESNO	CA	93727	07/01/2020
CH090390	THRIFTY PAYLESS, INC.	RITE AID #5817	8000 WHITE LANE	BAKERSFIELD	CA	93309	07/01/2020	12/11/2023
CH090390	THRIFTY PAYLESS, INC.	RITE AID #6303	3225 PANAMA LANE	BAKERSFIELD	CA	93313	07/01/2020
CH090390	THRIFTY PAYLESS, INC.	RITE AID #5816	715 AIRPORT DRIVE	BAKERSFIELD	CA	93308	07/01/2020
CH090390	THRIFTY PAYLESS, INC.	RITE AID #5869	3795 WEST SHIELDS AVENUE	FRESNO	CA	93722	07/01/2020
CH090390	THRIFTY PAYLESS, INC.	RITE AID #5811	1425 SOUTH H STREET	BAKERSFIELD	CA	93304	07/01/2020
CH090390	THRIFTY PAYLESS, INC.	RITE AID #6489	8008 PANAMA RD	LAMONT	CA	93241	07/01/2020
CH090390	THRIFTY PAYLESS, INC.	RITE AID #5847	811 TUCKER ROAD	TEHACHAPI	CA	93561	01/01/2022
CH090390	THRIFTY PAYLESS, INC.	RITE AID #5853	456 S MADERA AVENUE	KERMAN	CA	93630	01/01/2022
CH090390	VALLEY PHARMACY	LAMONT HEALTHCARE INC	10400 MAIN ST STE D	LAMONT	CA	93241	01/01/2023
CH090390	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/01/2019
CH090390	WAL-MART PHARMACY 10-1574	6225 COLONY STREET		BAKERSFIELD	CA	93307	04/01/2019
CH090390	WAL-MART PHARMACY 10-1624	2601 FASHION PLACE		BAKERSFIELD	CA	93306	04/01/2019
CH090390	WAL-MART PHARMACY 10-2001	5125 EAST KINGS CANYON		FRESNO	CA	93727	04/01/2019
CH090390	WAL-MART PHARMACY 10-2277	323 WEST SHAW AVE		CLOVIS	CA	93612	04/01/2019
CH090390	WAL-MART PHARMACY 10-5215	530 WOOLLOMES AVE		DELANO	CA	93215	01/01/2024
CH090390	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/01/2019
CH090390	WALGREEN CO	DBA: WALGREENS #09702	5785 N FIRST ST	FRESNO	CA	93710-6203	07/01/2013
CH090390	WALGREEN CO	DBA: WALGREENS #10243	2420 N BLACKSTONE AVE	FRESNO	CA	93703-1747	07/01/2013	01/28/2025
CH090390	WALGREEN CO	DBA: WALGREENS #10335	2424 N BRAWLEY AVE	FRESNO	CA	93722	07/01/2013
CH090390	WALGREEN CO	DBA: WALGREENS #11242	2020 W CLEVELAND AVE	MADERA	CA	93637	07/01/2013
CH090390	WALGREEN CO.	DBA: WALGREENS # 01816	3301 PANAMA LANE	BAKERSFIELD	CA	93313-3631	07/01/2013
CH090390	WALGREEN CO.	DBA: WALGREENS # 02702	1344 W CLINTON AVE	FRESNO	CA	93705	07/01/2013	08/20/2018
CH090390	WALGREEN CO.	DBA: WALGREENS # 03222	40 CHESTER AVENUE	BAKERSFIELD	CA	93301	07/01/2013	02/28/2023
CH090390	WALGREEN CO.	DBA: WALGREENS # 03272	3315 SOUTH H STREET	BAKERSFIELD	CA	93304	07/01/2013
CH090390	WALGREEN CO.	DBA: WALGREENS # 03282	3815 NILES STREET	BAKERSFIELD	CA	93306	07/01/2013	07/01/2015
CH090390	WALGREEN CO.	DBA: WALGREENS # 03294	2628 MOUNT VERNON AVENUE	BAKERSFIELD	CA	93306	07/01/2013
CH090390	WALGREEN CO.	DBA: WALGREENS # 04907	2840 W. ASHLAN AVE.	FRESNO	CA	93705	07/01/2013	08/20/2018
CH090390	WALGREEN CO.	DBA: WALGREENS # 05646	770 S HWY 160	PAHRUMP	NV	89048	07/01/2013	04/01/2019
CH090390	WALGREEN CO.	DBA: WALGREENS # 05847	610 E NEES AVENUE	FRESNO	CA	93720	07/01/2013
CH090390	WALGREEN CO.	DBA: WALGREENS # 06082	626 S CLOVIS AVE	FRESNO	CA	93727	07/01/2013
CH090390	WALGREEN CO.	DBA WALGREENS #06386	4810 E CESAR CHAVEZ BLVD	FRESNO	CA	93727	07/01/2013
CH090390	WALGREEN CO.	DBA: WALGREENS # 06387	1815 HERNDON AVE	CLOVIS	CA	93611	07/01/2013
CH090390	WALGREEN CO.	DBA: WALGREENS # 06526	9550 HAGEMAN ROAD	BAKERSFIELD	CA	93312	07/01/2013
CH090390	WALGREEN CO.	DBA: WALGREENS # 06942	6010 N FIGARDEN DRIVE	FRESNO	CA	93722-6030	07/01/2013
CH090390	WALGREEN CO.	DBA: WALGREENS # 07204	7015 N WEST AVE	FRESNO	CA	93711-0461	07/01/2013	04/28/2025
CH090390	WALGREEN CO.	DBA: WALGREENS # 07266	8975 N CHESTNUT AVE	FRESNO	CA	93720	07/01/2013
CH090390	WALGREEN CO.	DBA: WALGREENS # 07529	27983 SLOAN CANYON RD	CASTAIC	CA	91384	07/01/2013
CH090390	WALGREEN CO.	DBA: WALGREENS # 07830	205 W SHAW AVENUE	CLOVIS	CA	93612-3602	07/01/2013
CH090390	WALGREEN CO.	DBA: WALGREENS # 07909	4949 GOSFORD ROAD	BAKERSFIELD	CA	93313-4992	07/01/2013
CH090390	WALGREEN CO.	DBA: WALGREENS # 09655	6885 N WILLOW AVENUE	FRESNO	CA	93710	07/01/2013	10/30/2019
CH090390	WALGREEN CO.	DBA: WALGREENS # 10334	1790 SHAW AVE	CLOVIS	CA	93611	07/01/2013
CH090390	WALGREEN CO.	DBA WALGREENS #10827	1435 HIGH ST.	DELANO	CA	93215	07/01/2013
CH090390	WALGREEN CO.	DBA: WALGREENS #11532	3300 BUENA VISTA RD BLDG A	BAKERSFIELD	CA	93311	07/01/2013
CH090390	WALGREEN CO.	DBA: WALGREENS #11877	4771 W ASHLAN AVE	FRESNO	CA	93722	07/01/2013
CH090390	WALGREEN CO.	DBA: WALGREENS #12281	2950 N FOWLER WAY	FRESNO	CA	93727	07/01/2013	08/10/2015
CH090390	WALGREEN CO.	DBA: WALGREENS #12282	2589 JENSEN AVE	SANGER	CA	93657	07/01/2013
CH090390	WALGREEN CO.	DBA: WALGREENS #12574	1219 N CEDAR AVE	FRESNO	CA	93703	07/01/2013
CH090390	WALGREEN CO.	DBA: WALGREENS # 12707	4172 N. 1ST STREET	FRESNO	CA	93726	07/01/2013
CH090390	WALGREEN CO.	DBA: WALGREENS # 13871	1016 W SHAW AVE	FRESNO	CA	93711	07/01/2013
CH090390	WALGREEN CO.	DBA: WALGREENS # 06756	4306 MING AVE	BAKERSFIELD	CA	93309-4802	07/01/2013	01/29/2025
CH090390	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16382	2323 16TH ST STE 100	BAKERSFIELD	CA	93301	01/01/2016
CH090390	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #12761	41169 GOODWIN WAY STE 110	MADERA	CA	93636	01/01/2019
CH090390	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	07/01/2013	06/24/2015
CH090390	WALGREENS MAIL SERVICE, INC.		8337 S PARK CIRCLE	ORLANDO	FL	32819-9049	07/01/2013	06/24/2015
CH090390	WALMART PHARMACY 10-2689	3131 N CEDAR AVENUE		FRESNO	CA	93703	04/01/2019
CH090390	WALMART PHARMACY 10-3140	3111 NORTH CHESTER		BAKERSFIELD	CA	93308	01/01/2024
CH090390	WALMART PHARMACY 10-3141	5037 EAST BRUNDAGE LANE		BAKERSFIELD	CA	93307	01/01/2024
CH090390	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	01/01/2024
CH090390	WALMART PHARMACY 10-5632	1804 EAST ASHLAN AVE.		FRESNO	CA	93726	04/01/2019
CH090390	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024
CH090390	YOUR DRUG STORE INC	2303 NILES PT		BAKERSFIELD	CA	93306-4025	01/01/2019	03/30/2024
CH090390	ZOHA'S PHARMACY	5458 CALIFORNIA AVE		BAKERSFIELD	CA	93309-1618	04/01/2019	10/15/2021
CH090390	ZOHA'S PHARMACY	616 34TH ST		BAKERSFIELD	CA	93301-2208	04/01/2019	10/15/2021

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	NPI: Number	Insert	Recertification		1275161325	3/3/2025 4:50 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	3/3/2025 4:50 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1316575467	3/3/2025 4:50 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	3/3/2025 4:50 PM
Details	Last Recertification Date	Update	Recertification	2/13/2024 7:45:42 AM	3/3/2025 4:50:07 PM	3/3/2025 4:50 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1245008598	12/10/2024 6:42 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		CA	12/10/2024 6:42 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1508634858	12/10/2024 6:42 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		CA	12/10/2024 6:42 PM
Details	Entity Subname	Update	Change Request	Kern Mobile Unit	CLINICA SIERRA VISTA - Kern Mobile Unit	11/6/2024 8:11 AM
Contacts	Primary Contact	Update	Group Change Request	Andolfo, Kristin 340B Analyst Clinica Sierra Vista 9175020819	Marin-Gonzalez, Diane 340B Analyst Clinica Sierra Vista 9546865823	11/5/2024 10:19 AM
Addresses	Main Address	Update	Recertification	301 Brundage Ln Bakersfield, CA 93304-3635	301 Brundage Ln Bakersfield, CA 93304	2/13/2024 7:45 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1336544790 (CA)		2/13/2024 7:45 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1144897505	2/13/2024 7:45 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	2/13/2024 7:45 AM
Details	Last Recertification Date	Update	Recertification	2/14/2023 6:23:44 PM	2/13/2024 7:45:42 AM	2/13/2024 7:45 AM
Addresses	Billing Address	Update	Group Change Request	Clinica Sierra Vista 1430 Truxtun Ave 400 Bakersfield, CA 93301-1559	Clinica Sierra Vista 1430 Truxtun Ave, STE 400 PO BOX 1559 Bakersfield, CA 93301	1/24/2024 4:24 PM
Contacts	Primary Contact	Update	Group Change Request	Cortes, Beatrice 340B Program Manager Clinica Sierra Vista - 6616353050-2306	Andolfo, Kristin 340B Analyst Clinica Sierra Vista 9175020819	1/4/2024 3:31 PM
Contacts	Primary Contact	Update	Change Request	Leslie, Stephen Paul CFO Clinica Sierra Vista 6614282776	Cortes, Beatrice 340B Program Manager Clinica Sierra Vista - 6616353050-2306	9/29/2023 4:47 PM
Contacts	Authorizing Official	Update	Change Request	Cortes, Beatrice 340B Program Manager Clinica Sierra Vista - 6616353050-2306	Bhakta, Dixit Director of Pharmacy Clinica Sierra Vista 6617793118	9/29/2023 4:47 PM
Addresses	Main Address	Update	Change Request	705 S. Union Avenue Bakersfield, CA 93307-3635	301 Brundage Ln Bakersfield, CA 93304-3635	7/19/2023 9:57 AM
Addresses	Billing Address	Update	Recertification	Clinica Sierra Vista P O Box 1559 Bakersfield, CA 93302-1559	Clinica Sierra Vista 1430 Truxtun Ave 400 Bakersfield, CA 93301-1559	2/14/2023 6:23 PM
Details	Last Recertification Date	Update	Recertification	2/7/2022 3:08:02 PM	2/14/2023 6:23:44 PM	2/14/2023 6:23 PM
Contacts	Authorizing Official	Update	AO Change Request	Ferreira, Stacy Lynn CEO Clinica Sierra Vista 6616353050	Cortes, Beatrice 340B Program Manager Clinica Sierra Vista - 6616353050-2306	2/14/2023 4:45 PM
Contacts	Primary Contact	Update	Group Change Request	Banuelos, Nancy Deputy CEO Clinica Sierra Vista 6616353050	Leslie, Stephen Paul CFO Clinica Sierra Vista 6614282776	2/8/2022 10:23 AM
Details	Last Recertification Date	Update	Recertification	2/23/2021 2:12:51 PM	2/7/2022 3:08:02 PM	2/7/2022 3:08 PM
Contacts	Authorizing Official	Update	Profile Change Request	Ferreira, Stacy Lynn CEO (Interim) Clinica Sierra Vista 6616353050	Ferreira, Stacy Lynn CEO Clinica Sierra Vista 6616353050	7/15/2021 11:50 AM
Medicaid Billing	NPI: State	Update	Recertification		CA	2/23/2021 2:12 PM
Details	Last Recertification Date	Update	Recertification	2/20/2020 5:35:37 PM	2/23/2021 2:12:51 PM	2/23/2021 2:12 PM
Contacts	Primary Contact	Update	Change Request	Bookout, Pam Director of Pharmacy Clinica Sierra Vista 6616353050-2147	Banuelos, Nancy Deputy CEO Clinica Sierra Vista 6616353050	11/6/2020 7:19 AM
Contacts	Authorizing Official	Update	AO Change Request	Harris, Brian CEO Clinica Sierra Vista 6616353050-2152	Ferreira, Stacy Lynn CEO (Interim) Clinica Sierra Vista 6616353050	11/3/2020 12:23 PM
Details	Last Recertification Date	Update	Recertification	2/14/2019 12:44:36 PM	2/20/2020 5:35:37 PM	2/20/2020 5:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/14/2019 12:44 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1336544790	2/14/2019 12:44 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	2/14/2019 12:44 PM
Details	Last Recertification Date	Update	Recertification	2/8/2018 4:59:15 PM	2/14/2019 12:44:36 PM	2/14/2019 12:44 PM
Contacts	Primary Contact	Update	Profile Change Request	Bookout, Pam Director of Pharmacy Clinica Sierra Vista 6618453731-3151	Bookout, Pam Director of Pharmacy Clinica Sierra Vista 6616353050-2147	10/3/2018 1:52 PM
Contacts	Primary Contact	Update	Change Request	Stewart, Cindy Chief of Managed Care/Credentialing Clinica Sierra Vista 6616353050-2169	Bookout, Pam Director of Pharmacy Clinica Sierra Vista 6618453731-3151	7/25/2018 3:52 AM
Details	Is Authorizing Official EHB Data	Update	Change Request	False		7/25/2018 3:52 AM
Details	Last Recertification Date	Update	Recertification	2/6/2017 12:00:00 AM	2/8/2018 4:59:15 PM	2/8/2018 4:59 PM
Contacts	Authorizing Official	Update	AO Change Request	Schilling, Stephen W. CEO 6616353050-2152	Harris, Brian CEO Clinica Sierra Vista 6616353050-2152	2/1/2018 8:32 AM
Contacts	Primary Contact	Update	Profile Change Request	Stewart, Cindy Chief of Managed Care/Credentialing Clinica Sierra Vista 6616383050-2169	Stewart, Cindy Chief of Managed Care/Credentialing Clinica Sierra Vista 6616353050-2169	1/31/2018 3:09 PM
Contacts	Primary Contact	Update		Stewart, Cindy Chief of Managed Care/Credentialing 6616383050-2169	Stewart, Cindy Chief of Managed Care/Credentialing Clinica Sierra Vista 6616383050-2169	9/25/2017 3:06 PM
Contacts	Primary Contact	Insert			Stewart, Cindy Chief of Managed Care/Credentialing 6616383050-2169	8/2/2017 10:19 AM
Contacts	Authorizing Official	Insert			Schilling, Stephen W. CEO 6616353050-2152	6/30/2017 9:18 PM
Contacts	Signed By	Insert			Schilling, Stephen W. CEO 6616353050-2152	6/30/2017 9:18 PM
Addresses	Main Address	Insert			705 S. Union Avenue Bakersfield, CA 93307-3635	2/6/2017 1:29 PM
Details	Last Recertification Date	Update			2/6/2017 12:00:00 AM	2/6/2017 1:29 PM
Addresses	Billing Address	Insert			Clinica Sierra Vista P O Box 1559 Bakersfield, CA 93302-1559	2/16/2016 6:06 PM
Dates	Participating Approval Date	Update			2/16/2016 12:00:00 AM	2/16/2016 6:06 PM
Details	State	Update		Pending	Active	2/16/2016 6:06 PM
Dates	Start Date	Update			4/1/2016 12:00:00 AM	2/16/2016 6:06 PM
Details	340B ID	Update		ONLINE_REG_56714	CH09039AY	1/28/2016 8:12 AM
Medicaid Billing	NPI: Number	Insert			1336544790	1/6/2016 1:35 PM
Details	340B ID	Update		ONLINE_REG	ONLINE_REG_56714	1/6/2016 1:35 PM
Details	Last Recertification Date	Insert				1/6/2016 1:35 PM
Details	Grant Number	Insert			H80CS00540	1/6/2016 1:35 PM
Details	340B ID	Insert			ONLINE_REG	1/6/2016 1:35 PM
Details	Is Authorizing Official EHB Data	Insert			False	1/6/2016 1:35 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/6/2016 1:35 PM
Details	Medicare Provider Number	Insert				1/6/2016 1:35 PM
Details	Entity Name	Insert			CLINICA SIERRA VISTA	1/6/2016 1:35 PM
Details	Program Code	Insert			CH	1/6/2016 1:35 PM
Details	Entity Subname	Insert			Kern Mobile Unit	1/6/2016 1:35 PM
Dates	Participating Approval Date	Insert				1/6/2016 1:35 PM
Details	State	Insert			Pending	1/6/2016 1:35 PM
Dates	Registration Date	Insert			1/6/2016 12:00:00 AM	1/6/2016 1:35 PM
Dates	Signed By Date	Insert			1/6/2016 12:00:00 AM	1/6/2016 1:35 PM
Dates	Start Date	Insert				1/6/2016 1:35 PM
Terminations	Termination Comments	Insert				1/6/2016 1:35 PM
Terminations	Termination Date	Insert				1/6/2016 1:35 PM
Terminations	Termination Effective Date	Insert				1/6/2016 1:35 PM
Terminations	Termination Reason	Insert				1/6/2016 1:35 PM

340B Drug Pricing Program Database