Covered Entity Details

CH03075B EAST LIBERTY FAMILY HEALTH CARE CENTER (Active) - information as of 4/25/2025 9:23:04 PM

Main Details

Name

EAST LIBERTY FAMILY HEALTH CARE CENTER

Subdivision Name

Hosanna House - Dental Clinic

Type

HRSA-Funded Health Center

Site ID

BPS-H80-008709

340B ID

CH03075B

Grant Number

H80CS00664

Additional Details

Current Program Status

Active

Registration Date

7/6/2016

Participating Start Date

10/1/2016

Participating Approval Date

7/28/2016

Last Recertification Date

2/12/2025

Contacts

Authorizing Official

East Liberty Family HealthCare Center
arsenial teroy runion, Chief Executive Officer
(913) 201-7564

Primary Contact

East Liberty Family Health Care Center
Lauren Mongelluzzo, Director of Health Informatics
(412) 345-7857

Addresses

Street Address

807 Wallace Street
Wilkinsburg, PA 15221-2312

Billing Address

East Liberty Family Health Care Center-LL
7157 Mary Peck Bond Place
Attention Finance Dept
Pittsburgh, PA 15206

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
PA	1007524920001,1007524920019,1007524920020,1007524920021,1007524920015	1669709655,1902443260,1760642896,1003418831,1790443711,1164948733

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	GIANT EAGLE PHARMACY #0017	6401 PENN AVE		PITTSBURGH	PA	15206	07/08/2016	10/01/2016	05/15/2019	06/05/2019
Contract Detail	GIANT EAGLE PHARMACY #0040	5550 CENTRE AVE		PITTSBURGH	PA	15232	07/08/2016	10/01/2016	05/15/2019	06/05/2019
Contract Detail	GIANT EAGLE PHARMACY #0069	9001 FRANKSTOWN RD		PITTSBURGH	PA	15235	07/08/2016	10/01/2016	05/15/2019	06/05/2019
Contract Detail	GIANT EAGLE PHARMACY #0221	20160 CENTER RIDGE ROAD, SUITE 201		ROCKY RIVER	OH	44116	07/08/2016	10/01/2016	05/15/2019	06/05/2019
Contract Detail	GIANT EAGLE PHARMACY #1619	EDGEWOOD TOWNE CENTER	1705 SOUTH BRADDOCK AVE	PITTSBURGH	PA	15218	07/08/2016	10/01/2016	05/15/2019	06/05/2019
Contract Detail	GIANT EAGLE PHARMACY #8991	2500 LOVI RD		FREEDOM	PA	15042	07/08/2016	10/01/2016	05/15/2019	06/05/2019
Contract Detail	GIANT EAGLE SPECIALTY #0232		600 LINDBERGH DRIVE SUITE 300	MOON TOWNSHIP	PA	15108	07/08/2016	10/01/2016	03/21/2018	03/21/2018

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH030750	Active	BPS-H80-001707	EAST LIBERTY FAMILY HEALTH CARE CENTER	EAST LIBERTY FAMILY HEALTH CARE CENTER	6023 HARVARD STREET	PITTSBURGH	PA
CH03075A	Terminated	BPS-H80-000860	EAST LIBERTY FAMILY HEALTH CARE CENTER	LINCOLN-LEMINGTON FAM HLTH CARE	7171 Churchland St	Pittsburgh	PA
CH03075B	Active	BPS-H80-008709	EAST LIBERTY FAMILY HEALTH CARE CENTER	Hosanna House - Dental Clinic	807 Wallace Street	Wilkinsburg	PA
CH03075C	Terminated	BPS-H80-021276	East Liberty Family Health Care Center	East Liberty Family Health Care Center- HD	373 Burrows St	Pittsburgh	PA
CH03075D	Active	BPS-H80-033967	East Liberty Family Health Care Center, Inc.	ELFHCC- Lincoln Lemington	7157 Mary Peck Bond Place	Pittsburgh	PA
CH03075E	Active	BPS-H80-038937	East Liberty Family Health Care Center, Inc.	East Liberty Family Healthcare Center- Uptown/Hill District	1425 Forbes Ave	Pittsburgh	PA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH03075A	COORDINATED CARE NETWORK	COORDINATED CARE NETWORK	300 PENN CENTER BLVD STE 405	PITTSBURGH	PA	15235-5511	01/01/2003	05/31/2015
CH030750	GIANT EAGLE PHARMACY #0017	6401 PENN AVE		PITTSBURGH	PA	15206	07/01/2016	05/15/2019
CH03075A	GIANT EAGLE PHARMACY #0017	6401 PENN AVE		PITTSBURGH	PA	15206	07/01/2016	05/15/2019
CH03075B	GIANT EAGLE PHARMACY #0017	6401 PENN AVE		PITTSBURGH	PA	15206	10/01/2016	05/15/2019
CH030750	GIANT EAGLE PHARMACY #0017	6401 PENN AVE		PITTSBURGH	PA	15206	10/01/2022	02/05/2024
CH030750	GIANT EAGLE PHARMACY #0040	5550 CENTRE AVE		PITTSBURGH	PA	15232	07/01/2016	05/15/2019
CH03075A	GIANT EAGLE PHARMACY #0040	5550 CENTRE AVE		PITTSBURGH	PA	15232	07/01/2016	05/15/2019
CH03075B	GIANT EAGLE PHARMACY #0040	5550 CENTRE AVE		PITTSBURGH	PA	15232	10/01/2016	05/15/2019
CH030750	GIANT EAGLE PHARMACY #0040	5550 CENTRE AVE		PITTSBURGH	PA	15232	10/01/2022	02/05/2024
CH030750	GIANT EAGLE PHARMACY #0069	9001 FRANKSTOWN RD		PITTSBURGH	PA	15235	07/01/2016	05/15/2019
CH03075A	GIANT EAGLE PHARMACY #0069	9001 FRANKSTOWN RD		PITTSBURGH	PA	15235	07/01/2016	05/15/2019
CH03075B	GIANT EAGLE PHARMACY #0069	9001 FRANKSTOWN RD		PITTSBURGH	PA	15235	10/01/2016	05/15/2019
CH030750	GIANT EAGLE PHARMACY #0069	9001 FRANKSTOWN RD		PITTSBURGH	PA	15235	10/01/2022	02/05/2024
CH030750	GIANT EAGLE PHARMACY #0078	230 RODI ROAD		PITTSBURGH	PA	15235	07/01/2017	05/15/2019
CH030750	GIANT EAGLE PHARMACY #0221	20160 CENTER RIDGE ROAD, SUITE 201		ROCKY RIVER	OH	44116	07/01/2016	05/15/2019
CH03075A	GIANT EAGLE PHARMACY #0221	20160 CENTER RIDGE ROAD, SUITE 201		ROCKY RIVER	OH	44116	07/01/2016	05/15/2019
CH03075B	GIANT EAGLE PHARMACY #0221	20160 CENTER RIDGE ROAD, SUITE 201		ROCKY RIVER	OH	44116	10/01/2016	05/15/2019
CH030750	GIANT EAGLE PHARMACY #1619	EDGEWOOD TOWNE CENTER	1705 SOUTH BRADDOCK AVE	PITTSBURGH	PA	15218	07/01/2016	05/15/2019
CH03075A	GIANT EAGLE PHARMACY #1619	EDGEWOOD TOWNE CENTER	1705 SOUTH BRADDOCK AVE	PITTSBURGH	PA	15218	07/01/2016	05/15/2019
CH03075B	GIANT EAGLE PHARMACY #1619	EDGEWOOD TOWNE CENTER	1705 SOUTH BRADDOCK AVE	PITTSBURGH	PA	15218	10/01/2016	05/15/2019
CH030750	GIANT EAGLE PHARMACY #8991	2500 LOVI RD		FREEDOM	PA	15042	07/01/2016	05/15/2019
CH03075A	GIANT EAGLE PHARMACY #8991	2500 LOVI RD		FREEDOM	PA	15042	07/01/2016	05/15/2019
CH03075B	GIANT EAGLE PHARMACY #8991	2500 LOVI RD		FREEDOM	PA	15042	10/01/2016	05/15/2019
CH030750	GIANT EAGLE SPECIALTY #0232		600 LINDBERGH DRIVE SUITE 300	MOON TOWNSHIP	PA	15108	07/01/2016	02/21/2017
CH03075A	GIANT EAGLE SPECIALTY #0232		600 LINDBERGH DRIVE SUITE 300	MOON TOWNSHIP	PA	15108	07/01/2016	03/21/2018
CH03075B	GIANT EAGLE SPECIALTY #0232		600 LINDBERGH DRIVE SUITE 300	MOON TOWNSHIP	PA	15108	10/01/2016	03/21/2018
CH030750	PHYSICIAN'S RX PHARMACY, LLC	PHYSICIANS RX PHARMACY, LLC	9701 APOLLO DRIVE #400	LARGO	MD	20774	07/01/2015	04/05/2016
CH03075A	PHYSICIAN'S RX PHARMACY, LLC	PHYSICIANS RX PHARMACY, LLC	9701 APOLLO DRIVE #400	LARGO	MD	20774	07/01/2015	04/07/2016
CH030750	PHYSICIANS RX PHARMACY OF CLINTON, INC.	PHYSICIANS RX PHARMACY CLINTON	9131 PISCATAWAY ROAD SUITE 670	CLINTON	MD	20735	07/01/2015	04/05/2016
CH03075A	PHYSICIANS RX PHARMACY OF CLINTON, INC.	PHYSICIANS RX PHARMACY CLINTON	9131 PISCATAWAY ROAD SUITE 670	CLINTON	MD	20735	07/01/2015	04/07/2016

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	2/5/2024 10:31:38 AM	2/12/2025 10:51:04 AM	2/12/2025 10:51 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1164948733	9/9/2024 9:16 AM
Medicaid Billing	NPI: State	Insert	Change Request		PA	9/9/2024 9:16 AM
Contacts	Primary Contact	Update	Change Request	Wilder, Jazmen Operations Manager East Liberty Family Health Care Center 4126612802-1103	Mongelluzzo, Lauren Director of Health Informatics East Liberty Family Health Care Center 4123457857	8/21/2024 2:21 PM
Contacts	Primary Contact	Update	Change Request	Mongelluzzo, Lauren Director of Health Informatics East Liberty Family Health Care Center 4123457857	Wilder, Jazmen Operations Manager East Liberty Family Health Care Center 4126612802-1103	7/2/2024 1:19 PM
Contacts	Primary Contact	Update	Profile Change Request	Mongelluzzo, Lauren Quality Nurse East Liberty Family Health Care Center 4123457857	Mongelluzzo, Lauren Director of Health Informatics East Liberty Family Health Care Center 4123457857	3/1/2024 11:46 AM
Details	Last Recertification Date	Update	Recertification	2/13/2023 2:21:30 PM	2/5/2024 10:31:38 AM	2/5/2024 10:31 AM
Contacts	Authorizing Official	Update	AO Change Request	Anderson, Gregory C Interim CEO The East Liberty Family Health Care Center 4126612802	runion, arsenial teroy Chief Executive Officer East Liberty Family HealthCare Center 9132017564	2/5/2024 9:59 AM
Details	Last Recertification Date	Update	Recertification	2/10/2022 8:30:29 AM	2/13/2023 2:21:30 PM	2/13/2023 2:21 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100752492-0019 (PA)		11/18/2022 3:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/18/2022 3:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007524920001	11/18/2022 3:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	11/18/2022 3:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/18/2022 3:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007524920019	11/18/2022 3:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	11/18/2022 3:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/18/2022 3:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007524920020	11/18/2022 3:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	11/18/2022 3:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/18/2022 3:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007524920021	11/18/2022 3:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	11/18/2022 3:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1760642896	11/18/2022 3:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	11/18/2022 3:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1003418831	11/18/2022 3:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	11/18/2022 3:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1790443711	11/18/2022 3:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	11/18/2022 3:12 PM
Contacts	Primary Contact	Update	Profile Change Request	Mongelluzzo, Lauren Quality Nurse East Liberty Family Healthcare Center 4123457857	Mongelluzzo, Lauren Quality Nurse East Liberty Family Health Care Center 4123457857	11/18/2022 11:04 AM
Contacts	Primary Contact	Update	PC Change Request	Hampson, David 340B Program Coordinator East Liberty Family Health Care Center 4123450414	Mongelluzzo, Lauren Quality Nurse East Liberty Family Healthcare Center 4123457857	10/4/2022 6:53 AM
Contacts	Authorizing Official	Update	AO Change Request	Jones Sr., Rodney B. CEO East Liberty Family Health Care Center 4123626353	Anderson, Gregory C Interim CEO The East Liberty Family Health Care Center 4126612802	9/2/2022 3:19 PM
Addresses	Billing Address	Update	Recertification	East Liberty Family Health Care Center-LL 7171 Churchland Street Attention Finance Dept Pittsburgh, PA 15206	East Liberty Family Health Care Center-LL 7157 Mary Peck Bond Place Attention Finance Dept Pittsburgh, PA 15206	2/10/2022 8:30 AM
Contacts	Primary Contact	Update	Recertification	Fedor, Kim COO East Liberty Family Health Care Center 4123457855	Hampson, David 340B Program Coordinator East Liberty Family Health Care Center 4123450414	2/10/2022 8:30 AM
Details	Last Recertification Date	Update	Recertification	2/7/2021 10:26:15 AM	2/10/2022 8:30:29 AM	2/10/2022 8:30 AM
Contacts	Primary Contact	Update	Group Change Request	Stewart, Suanne Pharmacy Program Coordinator East Liberty Family Health Care Center 4123450414	Fedor, Kim COO East Liberty Family Health Care Center 4123457855	7/12/2021 7:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/7/2021 10:26 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		100752492-0019	2/7/2021 10:26 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	2/7/2021 10:26 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1902443260	2/7/2021 10:26 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	2/7/2021 10:26 AM
Details	Last Recertification Date	Update	Recertification	1/28/2020 11:23:25 AM	2/7/2021 10:26:15 AM	2/7/2021 10:26 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1669709655	12/13/2020 1:51 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	12/13/2020 1:51 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1669709655 ( )		12/13/2020 1:51 PM
Details	Last Recertification Date	Update	Recertification	2/4/2019 8:42:43 AM	1/28/2020 11:23:25 AM	1/28/2020 11:23 AM
Addresses	Billing Address	Update	Recertification	East Liberty Family Health Care Center-EL 6023 Harvard Street Pittsburgh, PA 15206-3053	East Liberty Family Health Care Center-LL 7171 Churchland Street Attention Finance Dept Pittsburgh, PA 15206	2/4/2019 8:42 AM
Details	Last Recertification Date	Update	Recertification	2/8/2018 7:51:06 AM	2/4/2019 8:42:43 AM	2/4/2019 8:42 AM
Details	Last Recertification Date	Update	Recertification	1/25/2017 12:00:00 AM	2/8/2018 7:51:06 AM	2/8/2018 7:51 AM
Addresses	Billing Address	Update	Change Request	East Liberty Family Health Care Center 7171 Churchland St. Pittsburgh, PA 15206	East Liberty Family Health Care Center-EL 6023 Harvard Street Pittsburgh, PA 15206-3053	11/22/2017 9:50 AM
Contacts	Primary Contact	Update	Profile Change Request	Stewart, Suanne Pharmacy Program Coordinator East Liberty family Health Care Center 4123450414	Stewart, Suanne Pharmacy Program Coordinator East Liberty Family Health Care Center 4123450414	11/20/2017 11:16 AM
Contacts	Primary Contact	Insert	Change Request		Stewart, Suanne Pharmacy Program Coordinator East Liberty family Health Care Center 4123450414	11/20/2017 10:46 AM
Details	Is Authorizing Official EHB Data	Update	Change Request	False		11/20/2017 10:46 AM
Contacts	Authorizing Official	Update		Jones Sr., Rodney B. CEO 4123626353	Jones Sr., Rodney B. CEO East Liberty Family Health Care Center 4123626353	10/4/2017 11:18 AM
Contacts	Signed By	Update		Jones Sr., Rodney B. CEO 4123626353	Jones Sr., Rodney B. CEO East Liberty Family Health Care Center 4123626353	10/4/2017 11:18 AM
Contacts	Authorizing Official	Insert			Jones Sr., Rodney B. CEO 4123626353	4/11/2017 3:10 PM
Contacts	Signed By	Insert			Jones Sr., Rodney B. CEO 4123626353	4/11/2017 3:10 PM
Addresses	Main Address	Insert			807 Wallace Street Wilkinsburg, PA 15221-2312	1/25/2017 3:30 PM
Details	Last Recertification Date	Update			1/25/2017 12:00:00 AM	1/25/2017 3:30 PM
Addresses	Billing Address	Insert			East Liberty Family Health Care Center 7171 Churchland St. Pittsburgh, PA 15206	7/28/2016 10:28 AM
Dates	Participating Approval Date	Update			7/28/2016 12:00:00 AM	7/28/2016 10:28 AM
Details	State	Update		Pending	Active	7/28/2016 10:28 AM
Dates	Start Date	Update			10/1/2016 12:00:00 AM	7/28/2016 10:28 AM
Details	340B ID	Update		ONLINE_REG_71000	CH03075B	7/19/2016 11:53 AM
Details	340B ID	Update		ONLINE_REG	ONLINE_REG_71000	7/6/2016 11:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/6/2016 11:01 AM
Medicaid Billing	Medicaid: Number	Insert			1007524920015	7/6/2016 11:01 AM
Medicaid Billing	Medicaid: State	Insert			PA	7/6/2016 11:01 AM
Medicaid Billing	NPI: Number	Insert			1669709655	7/6/2016 11:01 AM
Details	Last Recertification Date	Insert				7/6/2016 11:01 AM
Details	Grant Number	Insert			H80CS00664	7/6/2016 11:01 AM
Details	340B ID	Insert			ONLINE_REG	7/6/2016 11:01 AM
Details	Is Authorizing Official EHB Data	Insert			False	7/6/2016 11:01 AM
Dates	Last Date That 340B Drugs Purchased	Insert				7/6/2016 11:01 AM
Details	Medicare Provider Number	Insert				7/6/2016 11:01 AM
Details	Entity Name	Insert			EAST LIBERTY FAMILY HEALTH CARE CENTER	7/6/2016 11:01 AM
Details	Program Code	Insert			CH	7/6/2016 11:01 AM
Details	Entity Subname	Insert			Hosanna House - Dental Clinic	7/6/2016 11:01 AM
Dates	Participating Approval Date	Insert				7/6/2016 11:01 AM
Details	State	Insert			Pending	7/6/2016 11:01 AM
Dates	Registration Date	Insert			7/6/2016 12:00:00 AM	7/6/2016 11:01 AM
Dates	Signed By Date	Insert			7/6/2016 12:00:00 AM	7/6/2016 11:01 AM
Dates	Start Date	Insert				7/6/2016 11:01 AM
Terminations	Termination Comments	Insert				7/6/2016 11:01 AM
Terminations	Termination Date	Insert				7/6/2016 11:01 AM
Terminations	Termination Effective Date	Insert				7/6/2016 11:01 AM
Terminations	Termination Reason	Insert				7/6/2016 11:01 AM

340B Drug Pricing Program Database