Covered Entity Details

CH03414A SPECTRUM HEALTH SERVICES, INC. (Active) - information as of 5/24/2025 12:45:22 AM

Main Details

Name

SPECTRUM HEALTH SERVICES, INC.

Subdivision Name

BROAD STREET HEALTH CENTER

Type

HRSA-Funded Health Center

Site ID

BPS-H80-002951

340B ID

CH03414A

Grant Number

H80CS00389

Additional Details

Current Program Status

Active

Registration Date

7/13/2016

Participating Start Date

10/1/2016

Participating Approval Date

7/21/2016

Last Recertification Date

2/13/2025

Contacts

Authorizing Official

Spectrum Health Services, Inc
Shawna L Russell-Young, Chief Compliance Officer
(215) 668-0847

Primary Contact

Spectrum Health Services, Inc.
Suzanne Brown, Director of Pharmacy Services
(267) 769-2512

Addresses

Street Address

1415 N Broad St STE 224
Philadelphia, PA 19122-3325

Billing Address

Spectrum Health Services, Inc
5201 Haverford Avenue
Philadelphia, PA 19139

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	1007288260005	1881629012

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	BEST CARE PHARMACY	257 N 52ND ST		PHILADELPHIA	PA	19139	04/03/2019	07/01/2019	02/12/2024	07/17/2024
Contract Detail	BEST CARE PHARMACY II	269 S 52ND STREET		PHILADELPHIA	PA	19139-4108	04/03/2019	07/01/2019	07/12/2019	07/12/2019
Contract Detail	BEST CARE PHARMACY II	269 S 52ND STREET		PHILADELPHIA	PA	19139-4108	07/12/2019	10/01/2019	01/15/2021	10/05/2023
Contract Detail	BEST CARE PHARMACY III	4931 N BROAD ST		PHILADELPHIA	PA	19141	04/15/2019	07/01/2019	07/12/2019	07/12/2019
Contract Detail	BEST CARE PHARMACY III	4931 N BROAD ST		PHILADELPHIA	PA	19141	07/12/2019	10/01/2019	04/08/2021	10/05/2023
Contract Detail	COORDINATED CARE NETWORK	COORDINATED CARE NETWORK	300 PENN CENTER BLVD STE 405	PITTSBURGH	PA	15235-5511	04/03/2019	07/01/2019		07/01/2019
Contract Detail	ECKERD CORPORATION	RITE AID #11124	4055-89 MARKET STREET	PHILADELPHIA	PA	19104	04/03/2019	07/01/2019	08/24/2023	10/05/2023
Contract Detail	ECKERD CORPORATION	RITE AID #11125	7418 OXFORD AVE	PHILADELPHIA	PA	19111	07/15/2019	10/01/2019	08/24/2023	10/05/2023
Contract Detail	ECKERD CORPORATION	RITE AID #11136	1334 WINDRIM AVENUE	PHILADELPHIA	PA	19141	04/15/2025	07/01/2025		04/15/2025
Contract Detail	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02704	4849 MARKET ST.	PHILADELPHIA	PA	19139	04/03/2019	07/01/2019		07/01/2019
Contract Detail	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02755	4314 LOCUST STREET	PHILADELPHIA	PA	19104	10/05/2023	01/01/2024		01/01/2024
Contract Detail	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02077	1901 WEST OREGON AVENUE	PHILADELPHIA	PA	19145	10/05/2023	01/01/2024		01/01/2024
Contract Detail	PENNSYLVANIA CVS PHARMACY, L.L.C.	CVS/PHARMACY #11219	1138 N. 2ND STREET	PHILADELPHIA	PA	19123	04/09/2025	07/01/2025		04/09/2025
Contract Detail	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02397	8525 FRANKFORD AVENUE	PHILADELPHIA	PA	19136	04/09/2025	07/01/2025		04/09/2025
Contract Detail	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02266	6900 LINDBERGH BLVD.	PHILADELPHIA	PA	19142	04/09/2025	07/01/2025		04/09/2025
Contract Detail	PENNSYLVANIA CVS PHARMACY, L.L.C.	CVS/PHARMACY #11371	1717 NORTH 12TH STREET, UNIT F	PHILADELPHIA	PA	19122	04/09/2025	07/01/2025		04/09/2025
Contract Detail	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00371	6501 HARBISON AVENUE	PHILADELPHIA	PA	19149	04/09/2025	07/01/2025		04/09/2025
Contract Detail	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00460	101 CHESTER AVENUE	YEADON	PA	19050	04/09/2025	07/01/2025		04/09/2025
Contract Detail	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03142	119 E. BALTIMORE AVE.	LANSDOWNE	PA	19050	04/09/2025	07/01/2025		04/09/2025
Contract Detail	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05867	401 SPRING GARDEN ST.	PHILADELPHIA	PA	19123	04/09/2025	07/01/2025		04/09/2025
Contract Detail	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 5081	101 W CITY AVENUE	BALA CYNWYD	PA	19004	04/09/2025	07/01/2025		04/09/2025
Contract Detail	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02408	802 N LANSDOWNE AVE	DREXEL HILL	PA	19026	04/09/2025	07/01/2025		04/09/2025
Contract Detail	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02159	2320-26 FAIRMOUNT AVENUE	PHILADELPHIA	PA	19130	04/09/2025	07/01/2025		04/09/2025
Contract Detail	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02222	7520 CITY LINE AVE.	PHILADELPHIA	PA	19151	04/09/2025	07/01/2025		04/09/2025
Contract Detail	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 10090	2132 SOUTH STREET	PHILADELPHIA	PA	19146	04/09/2025	07/01/2025		04/09/2025
Contract Detail	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02074	4133 G ST.	PHILADELPHIA	PA	19124	04/09/2025	07/01/2025		04/09/2025
Contract Detail	PREMIER PHARMACY SERVICES	410 CLOVERLEAF DR		BALDWIN PARK	CA	91706	04/03/2019	07/01/2019	10/22/2020	10/05/2023
Contract Detail	PREMIER PHARMACY SERVICES	GOOD HEALTH INC.	1049-51 BROADWAY #2	BETHLEHEM	PA	18015-4148	04/03/2019	07/01/2019	10/22/2020	10/05/2023
Contract Detail	RITE AID OF NEW JERSEY, INC.	RITE AID #135	217 SUNSET ROAD	WILLINGBORO	NJ	08046	04/15/2025	07/01/2025		04/15/2025
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #2790	1406 CECIL B MOORE AVE	PHILADELPHIA	PA	19121	04/03/2019	07/01/2019	05/30/2019	05/30/2019
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #3213	4641-51 CHESTNUT STREET	PHILADELPHIA	PA	19139	04/03/2019	07/01/2019	08/24/2023	10/05/2023
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #1764	5627-99 CHESTNUT STREET	PHILADELPHIA	PA	19139	04/03/2019	07/01/2019	08/24/2023	10/05/2023
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #2451	5214-30 BALTIMORE AVENUE	PHILADELPHIA	PA	19143	04/03/2019	07/01/2019	08/24/2023	10/05/2023
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #1127	2131-59 NORTH BROAD STREET	PHILADELPHIA	PA	19122	04/03/2019	07/01/2019	08/24/2023	10/05/2023
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #3227	3000-02 REED STREET	PHILADELPHIA	PA	19146	04/03/2019	07/01/2019	08/24/2023	10/05/2023
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #2790	1406 CECIL B MOORE AVE	PHILADELPHIA	PA	19121	07/08/2019	10/01/2019	08/24/2023	10/05/2023
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #4611	5040 CITY LINE AVENUE	PHILADELPHIA	PA	19131	04/15/2025	07/01/2025		04/15/2025
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #1764	5627-99 CHESTNUT STREET	PHILADELPHIA	PA	19139	04/15/2025	07/01/2025		04/15/2025
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #872	164 WEST CHELTEN AVENUE	PHILADELPHIA	PA	19144	04/15/2025	07/01/2025		04/15/2025
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #3523	1105-09 N. 63RD STREET	PHILADELPHIA	PA	19151	04/15/2025	07/01/2025		04/15/2025
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #478	5400 RISING SUN AVENUE	PHILADELPHIA	PA	19120	04/15/2025	07/01/2025		04/15/2025
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #2451	5214-30 BALTIMORE AVENUE	PHILADELPHIA	PA	19143	04/15/2025	07/01/2025		04/15/2025
Contract Detail	RITECHOICE PHARMACY IV	4700 WISSAHICKON AVE	BUILDING E, SUITE 100	PHILADELPHIA	PA	19144	04/03/2019	07/01/2019	07/30/2020	07/30/2020
Contract Detail	RITECHOICE PHARMACY V	5201 HAVERFORD AVE	FL 1	PHILADELPHIA	PA	19139-1401	07/11/2019	10/01/2019		10/01/2019
Contract Detail	SUN RAY DRUG, LLC	142 S 52ND STREET		PHILADELPHIA	PA	19139	10/05/2023	01/01/2024		01/01/2024
Contract Detail	SUNRAY DRUGS PROGRESS PLAZA	1501 N BROAD ST STE 9		PHILADELPHIA	PA	19122	04/03/2019	07/01/2019		07/01/2019
Contract Detail	SUNRAY DRUGS SPECIALTY	142 S 52ND ST	SUITE 201	PHILADELPHIA	PA	19139	10/05/2023	01/01/2024		01/01/2024
Contract Detail	THRIFT DRUG, INC.	RITE AID #11130	7700 CRITTENDEN STREET SUITE 101C	PHILADELPHIA	PA	19118	04/15/2025	07/01/2025		04/15/2025
Contract Detail	THRIFT DRUG, INC.	RITE AID #11122	284 EAST LANCASTER AVENUE	WYNNEWOOD	PA	19096	04/15/2025	07/01/2025		04/15/2025
Contract Detail	THRIFT DRUG, INC.	RITE AID #11105	832 NORTH LANSDOWNE AVE.	DREXEL HILL	PA	19026	04/15/2025	07/01/2025		04/15/2025
Contract Detail	WAL-MART PHARMACY 10-2040	2106 MT HOLLY RD		BURLINGTON	NJ	08016	04/03/2019	07/01/2019	07/08/2019	07/08/2019
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/03/2019	07/01/2019	07/08/2019	07/08/2019
Contract Detail	WALMART PHARMACY 10-3585	2901 RILEY FUZZELL RD		SPRING	TX	77386	04/03/2019	07/01/2019	07/08/2019	07/08/2019

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	Address Cont.	City	State
CH034140	Active	BPS-H80-012685	SPECTRUM HEALTH SERVICES, INC.	Spectrum Community Health Center	5201 Haverford Avenue		Philadelphia	PA
CH03414A	Active	BPS-H80-002951	SPECTRUM HEALTH SERVICES, INC.	BROAD STREET HEALTH CENTER	1415 N Broad St STE 224		Philadelphia	PA
CH03414B	Active	BPS-H80-017169	SPECTRUM HEALTH SERVICES, INC.	Reed Street Health Center	1325 South 33rd Street	Suite 300	Philadelphia	PA
CH03414C	Active	BPS-H80-033716	SPECTRUM HEALTH SERVICES	Cottman Avenue Health Center	3525 Cottman Ave		Philadelphia	PA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH034140	BEST CARE PHARMACY	257 N 52ND ST		PHILADELPHIA	PA	19139	01/01/2019	02/12/2024
CH03414A	BEST CARE PHARMACY	257 N 52ND ST		PHILADELPHIA	PA	19139	07/01/2019	02/12/2024
CH03414B	BEST CARE PHARMACY	257 N 52ND ST		PHILADELPHIA	PA	19139	07/01/2019	02/12/2024
CH03414A	BEST CARE PHARMACY II	269 S 52ND STREET		PHILADELPHIA	PA	19139-4108	07/01/2019	07/12/2019
CH03414B	BEST CARE PHARMACY II	269 S 52ND STREET		PHILADELPHIA	PA	19139-4108	07/01/2019	07/12/2019
CH034140	BEST CARE PHARMACY II	269 S 52ND STREET		PHILADELPHIA	PA	19139-4108	07/01/2019	06/12/2019
CH034140	BEST CARE PHARMACY II	269 S 52ND STREET		PHILADELPHIA	PA	19139-4108	10/01/2019	01/15/2021
CH03414A	BEST CARE PHARMACY II	269 S 52ND STREET		PHILADELPHIA	PA	19139-4108	10/01/2019	01/15/2021
CH03414B	BEST CARE PHARMACY II	269 S 52ND STREET		PHILADELPHIA	PA	19139-4108	10/01/2019	01/15/2021
CH034140	BEST CARE PHARMACY III	4931 N BROAD ST		PHILADELPHIA	PA	19141	07/01/2019	06/12/2019
CH03414A	BEST CARE PHARMACY III	4931 N BROAD ST		PHILADELPHIA	PA	19141	07/01/2019	07/12/2019
CH03414B	BEST CARE PHARMACY III	4931 N BROAD ST		PHILADELPHIA	PA	19141	07/01/2019	07/12/2019
CH034140	BEST CARE PHARMACY III	4931 N BROAD ST		PHILADELPHIA	PA	19141	10/01/2019	04/08/2021
CH03414A	BEST CARE PHARMACY III	4931 N BROAD ST		PHILADELPHIA	PA	19141	10/01/2019	04/08/2021
CH03414B	BEST CARE PHARMACY III	4931 N BROAD ST		PHILADELPHIA	PA	19141	10/01/2019	04/08/2021
CH034140	COORDINATED CARE NETWORK	COORDINATED CARE NETWORK	300 PENN CENTER BLVD STE 405	PITTSBURGH	PA	15235-5511	10/21/2010
CH03414A	COORDINATED CARE NETWORK	COORDINATED CARE NETWORK	300 PENN CENTER BLVD STE 405	PITTSBURGH	PA	15235-5511	07/01/2019
CH03414B	COORDINATED CARE NETWORK	COORDINATED CARE NETWORK	300 PENN CENTER BLVD STE 405	PITTSBURGH	PA	15235-5511	07/01/2019
CH03414C	COORDINATED CARE NETWORK	COORDINATED CARE NETWORK	300 PENN CENTER BLVD STE 405	PITTSBURGH	PA	15235-5511	01/01/2024
CH034140	ECKERD CORPORATION	RITE AID #11124	4055-89 MARKET STREET	PHILADELPHIA	PA	19104	01/01/2019	08/24/2023
CH03414A	ECKERD CORPORATION	RITE AID #11124	4055-89 MARKET STREET	PHILADELPHIA	PA	19104	07/01/2019	08/24/2023
CH03414B	ECKERD CORPORATION	RITE AID #11124	4055-89 MARKET STREET	PHILADELPHIA	PA	19104	07/01/2019	08/24/2023
CH034140	ECKERD CORPORATION	RITE AID #11125	7418 OXFORD AVE	PHILADELPHIA	PA	19111	10/01/2019	07/15/2019
CH034140	ECKERD CORPORATION	RITE AID #11125	7418 OXFORD AVE	PHILADELPHIA	PA	19111	10/01/2019	08/24/2023
CH03414A	ECKERD CORPORATION	RITE AID #11125	7418 OXFORD AVE	PHILADELPHIA	PA	19111	10/01/2019	08/24/2023
CH03414B	ECKERD CORPORATION	RITE AID #11125	7418 OXFORD AVE	PHILADELPHIA	PA	19111	10/01/2019	08/24/2023
CH03414A	ECKERD CORPORATION	RITE AID #11136	1334 WINDRIM AVENUE	PHILADELPHIA	PA	19141	07/01/2025
CH03414C	ECKERD CORPORATION	RITE AID #11136	1334 WINDRIM AVENUE	PHILADELPHIA	PA	19141	07/01/2025
CH03414B	ECKERD CORPORATION	RITE AID #11136	1334 WINDRIM AVENUE	PHILADELPHIA	PA	19141	07/01/2025
CH034140	ECKERD CORPORATION	RITE AID #11136	1334 WINDRIM AVENUE	PHILADELPHIA	PA	19141	07/01/2025
CH034140	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02704	4849 MARKET ST.	PHILADELPHIA	PA	19139	01/01/2019
CH03414A	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02704	4849 MARKET ST.	PHILADELPHIA	PA	19139	07/01/2019
CH03414B	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02704	4849 MARKET ST.	PHILADELPHIA	PA	19139	07/01/2019
CH034140	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02077	1901 WEST OREGON AVENUE	PHILADELPHIA	PA	19145	07/01/2021
CH034140	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02755	4314 LOCUST STREET	PHILADELPHIA	PA	19104	07/01/2021
CH03414A	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02755	4314 LOCUST STREET	PHILADELPHIA	PA	19104	01/01/2024
CH03414A	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02077	1901 WEST OREGON AVENUE	PHILADELPHIA	PA	19145	01/01/2024
CH03414B	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02755	4314 LOCUST STREET	PHILADELPHIA	PA	19104	01/01/2024
CH03414B	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02077	1901 WEST OREGON AVENUE	PHILADELPHIA	PA	19145	01/01/2024
CH03414C	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02755	4314 LOCUST STREET	PHILADELPHIA	PA	19104	01/01/2024
CH03414C	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02704	4849 MARKET ST.	PHILADELPHIA	PA	19139	01/01/2024
CH03414C	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02077	1901 WEST OREGON AVENUE	PHILADELPHIA	PA	19145	01/01/2024
CH034140	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02159	2320-26 FAIRMOUNT AVENUE	PHILADELPHIA	PA	19130	07/01/2025
CH034140	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00460	101 CHESTER AVENUE	YEADON	PA	19050	07/01/2025
CH034140	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02222	7520 CITY LINE AVE.	PHILADELPHIA	PA	19151	07/01/2025
CH034140	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00371	6501 HARBISON AVENUE	PHILADELPHIA	PA	19149	07/01/2025
CH034140	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02074	4133 G ST.	PHILADELPHIA	PA	19124	07/01/2025
CH034140	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03142	119 E. BALTIMORE AVE.	LANSDOWNE	PA	19050	07/01/2025
CH034140	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02408	802 N LANSDOWNE AVE	DREXEL HILL	PA	19026	07/01/2025
CH034140	PENNSYLVANIA CVS PHARMACY, L.L.C.	CVS/PHARMACY #11371	1717 NORTH 12TH STREET, UNIT F	PHILADELPHIA	PA	19122	07/01/2025
CH034140	PENNSYLVANIA CVS PHARMACY, L.L.C.	CVS/PHARMACY #11219	1138 N. 2ND STREET	PHILADELPHIA	PA	19123	07/01/2025
CH034140	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 10090	2132 SOUTH STREET	PHILADELPHIA	PA	19146	07/01/2025
CH034140	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 5081	101 W CITY AVENUE	BALA CYNWYD	PA	19004	07/01/2025
CH034140	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05867	401 SPRING GARDEN ST.	PHILADELPHIA	PA	19123	07/01/2025
CH034140	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02397	8525 FRANKFORD AVENUE	PHILADELPHIA	PA	19136	07/01/2025
CH034140	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02266	6900 LINDBERGH BLVD.	PHILADELPHIA	PA	19142	07/01/2025
CH03414C	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02266	6900 LINDBERGH BLVD.	PHILADELPHIA	PA	19142	07/01/2025
CH03414B	PENNSYLVANIA CVS PHARMACY, L.L.C.	CVS/PHARMACY #11371	1717 NORTH 12TH STREET, UNIT F	PHILADELPHIA	PA	19122	07/01/2025
CH03414B	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02222	7520 CITY LINE AVE.	PHILADELPHIA	PA	19151	07/01/2025
CH03414B	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00371	6501 HARBISON AVENUE	PHILADELPHIA	PA	19149	07/01/2025
CH03414C	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05867	401 SPRING GARDEN ST.	PHILADELPHIA	PA	19123	07/01/2025
CH03414C	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 5081	101 W CITY AVENUE	BALA CYNWYD	PA	19004	07/01/2025
CH03414C	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02222	7520 CITY LINE AVE.	PHILADELPHIA	PA	19151	07/01/2025
CH03414C	PENNSYLVANIA CVS PHARMACY, L.L.C.	CVS/PHARMACY #11371	1717 NORTH 12TH STREET, UNIT F	PHILADELPHIA	PA	19122	07/01/2025
CH03414A	PENNSYLVANIA CVS PHARMACY, L.L.C.	CVS/PHARMACY #11219	1138 N. 2ND STREET	PHILADELPHIA	PA	19123	07/01/2025
CH03414B	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02266	6900 LINDBERGH BLVD.	PHILADELPHIA	PA	19142	07/01/2025
CH03414B	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02159	2320-26 FAIRMOUNT AVENUE	PHILADELPHIA	PA	19130	07/01/2025
CH03414C	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03142	119 E. BALTIMORE AVE.	LANSDOWNE	PA	19050	07/01/2025
CH03414A	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02397	8525 FRANKFORD AVENUE	PHILADELPHIA	PA	19136	07/01/2025
CH03414A	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02266	6900 LINDBERGH BLVD.	PHILADELPHIA	PA	19142	07/01/2025
CH03414C	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00460	101 CHESTER AVENUE	YEADON	PA	19050	07/01/2025
CH03414A	PENNSYLVANIA CVS PHARMACY, L.L.C.	CVS/PHARMACY #11371	1717 NORTH 12TH STREET, UNIT F	PHILADELPHIA	PA	19122	07/01/2025
CH03414B	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 10090	2132 SOUTH STREET	PHILADELPHIA	PA	19146	07/01/2025
CH03414C	PENNSYLVANIA CVS PHARMACY, L.L.C.	CVS/PHARMACY #11219	1138 N. 2ND STREET	PHILADELPHIA	PA	19123	07/01/2025
CH03414A	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00371	6501 HARBISON AVENUE	PHILADELPHIA	PA	19149	07/01/2025
CH03414B	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 5081	101 W CITY AVENUE	BALA CYNWYD	PA	19004	07/01/2025
CH03414A	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00460	101 CHESTER AVENUE	YEADON	PA	19050	07/01/2025
CH03414A	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03142	119 E. BALTIMORE AVE.	LANSDOWNE	PA	19050	07/01/2025
CH03414A	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05867	401 SPRING GARDEN ST.	PHILADELPHIA	PA	19123	07/01/2025
CH03414C	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02408	802 N LANSDOWNE AVE	DREXEL HILL	PA	19026	07/01/2025
CH03414A	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 5081	101 W CITY AVENUE	BALA CYNWYD	PA	19004	07/01/2025
CH03414A	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02408	802 N LANSDOWNE AVE	DREXEL HILL	PA	19026	07/01/2025
CH03414A	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02159	2320-26 FAIRMOUNT AVENUE	PHILADELPHIA	PA	19130	07/01/2025
CH03414B	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02074	4133 G ST.	PHILADELPHIA	PA	19124	07/01/2025
CH03414B	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02397	8525 FRANKFORD AVENUE	PHILADELPHIA	PA	19136	07/01/2025
CH03414C	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00371	6501 HARBISON AVENUE	PHILADELPHIA	PA	19149	07/01/2025
CH03414C	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02397	8525 FRANKFORD AVENUE	PHILADELPHIA	PA	19136	07/01/2025
CH03414B	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02408	802 N LANSDOWNE AVE	DREXEL HILL	PA	19026	07/01/2025
CH03414C	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02159	2320-26 FAIRMOUNT AVENUE	PHILADELPHIA	PA	19130	07/01/2025
CH03414C	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02074	4133 G ST.	PHILADELPHIA	PA	19124	07/01/2025
CH03414A	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02222	7520 CITY LINE AVE.	PHILADELPHIA	PA	19151	07/01/2025
CH03414B	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05867	401 SPRING GARDEN ST.	PHILADELPHIA	PA	19123	07/01/2025
CH03414A	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 10090	2132 SOUTH STREET	PHILADELPHIA	PA	19146	07/01/2025
CH03414B	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00460	101 CHESTER AVENUE	YEADON	PA	19050	07/01/2025
CH03414C	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 10090	2132 SOUTH STREET	PHILADELPHIA	PA	19146	07/01/2025
CH03414B	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03142	119 E. BALTIMORE AVE.	LANSDOWNE	PA	19050	07/01/2025
CH03414A	PENNSYLVANIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02074	4133 G ST.	PHILADELPHIA	PA	19124	07/01/2025
CH03414B	PENNSYLVANIA CVS PHARMACY, L.L.C.	CVS/PHARMACY #11219	1138 N. 2ND STREET	PHILADELPHIA	PA	19123	07/01/2025
CH034140	PREMIER PHARMACY SERVICES	410 CLOVERLEAF DR		BALDWIN PARK	CA	91706	01/01/2019	10/22/2020
CH034140	PREMIER PHARMACY SERVICES	GOOD HEALTH INC.	1049-51 BROADWAY #2	BETHLEHEM	PA	18015-4148	01/01/2019	10/22/2020
CH03414A	PREMIER PHARMACY SERVICES	410 CLOVERLEAF DR		BALDWIN PARK	CA	91706	07/01/2019	10/22/2020
CH03414A	PREMIER PHARMACY SERVICES	GOOD HEALTH INC.	1049-51 BROADWAY #2	BETHLEHEM	PA	18015-4148	07/01/2019	10/22/2020
CH03414B	PREMIER PHARMACY SERVICES	410 CLOVERLEAF DR		BALDWIN PARK	CA	91706	07/01/2019	10/22/2020
CH03414B	PREMIER PHARMACY SERVICES	GOOD HEALTH INC.	1049-51 BROADWAY #2	BETHLEHEM	PA	18015-4148	07/01/2019	10/22/2020
CH03414A	RITE AID OF NEW JERSEY, INC.	RITE AID #135	217 SUNSET ROAD	WILLINGBORO	NJ	08046	07/01/2025
CH03414B	RITE AID OF NEW JERSEY, INC.	RITE AID #135	217 SUNSET ROAD	WILLINGBORO	NJ	08046	07/01/2025
CH03414C	RITE AID OF NEW JERSEY, INC.	RITE AID #135	217 SUNSET ROAD	WILLINGBORO	NJ	08046	07/01/2025
CH034140	RITE AID OF NEW JERSEY, INC.	RITE AID #135	217 SUNSET ROAD	WILLINGBORO	NJ	08046	07/01/2025
CH034140	RITE AID OF PENNSYLVANIA, LLC	RITE AID #1764	5627-99 CHESTNUT STREET	PHILADELPHIA	PA	19139	01/01/2019	08/24/2023
CH034140	RITE AID OF PENNSYLVANIA, LLC	RITE AID #3681	5440 LANSDOWNE AVENUE	PHILADELPHIA	PA	19131	01/01/2019	08/24/2023
CH034140	RITE AID OF PENNSYLVANIA, LLC	RITE AID #2451	5214-30 BALTIMORE AVENUE	PHILADELPHIA	PA	19143	01/01/2019	08/24/2023
CH034140	RITE AID OF PENNSYLVANIA, LLC	RITE AID #1127	2131-59 NORTH BROAD STREET	PHILADELPHIA	PA	19122	01/01/2019	08/24/2024
CH034140	RITE AID OF PENNSYLVANIA, LLC	RITE AID #3227	3000-02 REED STREET	PHILADELPHIA	PA	19146	01/01/2019	08/24/2023
CH03414A	RITE AID OF PENNSYLVANIA, LLC	RITE AID #2790	1406 CECIL B MOORE AVE	PHILADELPHIA	PA	19121	07/01/2019	05/30/2019
CH03414A	RITE AID OF PENNSYLVANIA, LLC	RITE AID #3213	4641-51 CHESTNUT STREET	PHILADELPHIA	PA	19139	07/01/2019	08/24/2023
CH03414A	RITE AID OF PENNSYLVANIA, LLC	RITE AID #1764	5627-99 CHESTNUT STREET	PHILADELPHIA	PA	19139	07/01/2019	08/24/2023
CH03414A	RITE AID OF PENNSYLVANIA, LLC	RITE AID #2451	5214-30 BALTIMORE AVENUE	PHILADELPHIA	PA	19143	07/01/2019	08/24/2023
CH03414A	RITE AID OF PENNSYLVANIA, LLC	RITE AID #1127	2131-59 NORTH BROAD STREET	PHILADELPHIA	PA	19122	07/01/2019	08/24/2023
CH03414A	RITE AID OF PENNSYLVANIA, LLC	RITE AID #3227	3000-02 REED STREET	PHILADELPHIA	PA	19146	07/01/2019	08/24/2023
CH034140	RITE AID OF PENNSYLVANIA, LLC	RITE AID #2790	1406 CECIL B MOORE AVE	PHILADELPHIA	PA	19121	07/01/2019	05/30/2019
CH034140	RITE AID OF PENNSYLVANIA, LLC	RITE AID #3213	4641-51 CHESTNUT STREET	PHILADELPHIA	PA	19139	07/01/2019	05/30/2019
CH03414B	RITE AID OF PENNSYLVANIA, LLC	RITE AID #2790	1406 CECIL B MOORE AVE	PHILADELPHIA	PA	19121	07/01/2019	05/30/2019
CH03414B	RITE AID OF PENNSYLVANIA, LLC	RITE AID #3213	4641-51 CHESTNUT STREET	PHILADELPHIA	PA	19139	07/01/2019	05/30/2019
CH03414B	RITE AID OF PENNSYLVANIA, LLC	RITE AID #1764	5627-99 CHESTNUT STREET	PHILADELPHIA	PA	19139	07/01/2019	08/24/2023
CH03414B	RITE AID OF PENNSYLVANIA, LLC	RITE AID #2451	5214-30 BALTIMORE AVENUE	PHILADELPHIA	PA	19143	07/01/2019	08/24/2023
CH03414B	RITE AID OF PENNSYLVANIA, LLC	RITE AID #1127	2131-59 NORTH BROAD STREET	PHILADELPHIA	PA	19122	07/01/2019	08/24/2023
CH03414B	RITE AID OF PENNSYLVANIA, LLC	RITE AID #3227	3000-02 REED STREET	PHILADELPHIA	PA	19146	07/01/2019	08/24/2023
CH034140	RITE AID OF PENNSYLVANIA, LLC	RITE AID #3213	4641-51 CHESTNUT STREET	PHILADELPHIA	PA	19139	10/01/2019	08/24/2023
CH03414A	RITE AID OF PENNSYLVANIA, LLC	RITE AID #2790	1406 CECIL B MOORE AVE	PHILADELPHIA	PA	19121	10/01/2019	08/24/2023
CH034140	RITE AID OF PENNSYLVANIA, LLC	RITE AID #2790	1406 CECIL B MOORE AVE	PHILADELPHIA	PA	19121	10/01/2019	08/24/2023
CH03414C	RITE AID OF PENNSYLVANIA, LLC	RITE AID #3523	1105-09 N. 63RD STREET	PHILADELPHIA	PA	19151	07/01/2025
CH03414B	RITE AID OF PENNSYLVANIA, LLC	RITE AID #478	5400 RISING SUN AVENUE	PHILADELPHIA	PA	19120	07/01/2025
CH034140	RITE AID OF PENNSYLVANIA, LLC	RITE AID #478	5400 RISING SUN AVENUE	PHILADELPHIA	PA	19120	07/01/2025
CH034140	RITE AID OF PENNSYLVANIA, LLC	RITE AID #1764	5627-99 CHESTNUT STREET	PHILADELPHIA	PA	19139	07/01/2025
CH03414C	RITE AID OF PENNSYLVANIA, LLC	RITE AID #1764	5627-99 CHESTNUT STREET	PHILADELPHIA	PA	19139	07/01/2025
CH03414B	RITE AID OF PENNSYLVANIA, LLC	RITE AID #872	164 WEST CHELTEN AVENUE	PHILADELPHIA	PA	19144	07/01/2025
CH03414C	RITE AID OF PENNSYLVANIA, LLC	RITE AID #872	164 WEST CHELTEN AVENUE	PHILADELPHIA	PA	19144	07/01/2025
CH03414C	RITE AID OF PENNSYLVANIA, LLC	RITE AID #478	5400 RISING SUN AVENUE	PHILADELPHIA	PA	19120	07/01/2025
CH03414B	RITE AID OF PENNSYLVANIA, LLC	RITE AID #4611	5040 CITY LINE AVENUE	PHILADELPHIA	PA	19131	07/01/2025
CH03414C	RITE AID OF PENNSYLVANIA, LLC	RITE AID #2451	5214-30 BALTIMORE AVENUE	PHILADELPHIA	PA	19143	07/01/2025
CH034140	RITE AID OF PENNSYLVANIA, LLC	RITE AID #872	164 WEST CHELTEN AVENUE	PHILADELPHIA	PA	19144	07/01/2025
CH03414B	RITE AID OF PENNSYLVANIA, LLC	RITE AID #3523	1105-09 N. 63RD STREET	PHILADELPHIA	PA	19151	07/01/2025
CH034140	RITE AID OF PENNSYLVANIA, LLC	RITE AID #2451	5214-30 BALTIMORE AVENUE	PHILADELPHIA	PA	19143	07/01/2025
CH03414A	RITE AID OF PENNSYLVANIA, LLC	RITE AID #4611	5040 CITY LINE AVENUE	PHILADELPHIA	PA	19131	07/01/2025
CH03414A	RITE AID OF PENNSYLVANIA, LLC	RITE AID #1764	5627-99 CHESTNUT STREET	PHILADELPHIA	PA	19139	07/01/2025
CH03414B	RITE AID OF PENNSYLVANIA, LLC	RITE AID #2451	5214-30 BALTIMORE AVENUE	PHILADELPHIA	PA	19143	07/01/2025
CH03414A	RITE AID OF PENNSYLVANIA, LLC	RITE AID #872	164 WEST CHELTEN AVENUE	PHILADELPHIA	PA	19144	07/01/2025
CH03414B	RITE AID OF PENNSYLVANIA, LLC	RITE AID #1764	5627-99 CHESTNUT STREET	PHILADELPHIA	PA	19139	07/01/2025
CH034140	RITE AID OF PENNSYLVANIA, LLC	RITE AID #4611	5040 CITY LINE AVENUE	PHILADELPHIA	PA	19131	07/01/2025
CH03414A	RITE AID OF PENNSYLVANIA, LLC	RITE AID #3523	1105-09 N. 63RD STREET	PHILADELPHIA	PA	19151	07/01/2025
CH03414A	RITE AID OF PENNSYLVANIA, LLC	RITE AID #478	5400 RISING SUN AVENUE	PHILADELPHIA	PA	19120	07/01/2025
CH03414A	RITE AID OF PENNSYLVANIA, LLC	RITE AID #2451	5214-30 BALTIMORE AVENUE	PHILADELPHIA	PA	19143	07/01/2025
CH034140	RITE AID OF PENNSYLVANIA, LLC	RITE AID #3523	1105-09 N. 63RD STREET	PHILADELPHIA	PA	19151	07/01/2025
CH03414C	RITE AID OF PENNSYLVANIA, LLC	RITE AID #4611	5040 CITY LINE AVENUE	PHILADELPHIA	PA	19131	07/01/2025
CH034140	RITECHOICE PHARMACY IV	4700 WISSAHICKON AVE	BUILDING E, SUITE 100	PHILADELPHIA	PA	19144	01/01/2019	07/30/2020
CH03414A	RITECHOICE PHARMACY IV	4700 WISSAHICKON AVE	BUILDING E, SUITE 100	PHILADELPHIA	PA	19144	07/01/2019	07/30/2020
CH03414B	RITECHOICE PHARMACY IV	4700 WISSAHICKON AVE	BUILDING E, SUITE 100	PHILADELPHIA	PA	19144	07/01/2019	07/30/2020
CH034140	RITECHOICE PHARMACY V	5201 HAVERFORD AVE	FL 1	PHILADELPHIA	PA	19139-1401	10/01/2019
CH03414A	RITECHOICE PHARMACY V	5201 HAVERFORD AVE	FL 1	PHILADELPHIA	PA	19139-1401	10/01/2019
CH03414B	RITECHOICE PHARMACY V	5201 HAVERFORD AVE	FL 1	PHILADELPHIA	PA	19139-1401	10/01/2019
CH03414C	RITECHOICE PHARMACY V	5201 HAVERFORD AVE	FL 1	PHILADELPHIA	PA	19139-1401	01/01/2024
CH034140	SUN RAY DRUG, LLC	142 S 52ND STREET		PHILADELPHIA	PA	19139	10/01/2020
CH03414A	SUN RAY DRUG, LLC	142 S 52ND STREET		PHILADELPHIA	PA	19139	01/01/2024
CH03414B	SUN RAY DRUG, LLC	142 S 52ND STREET		PHILADELPHIA	PA	19139	01/01/2024
CH03414C	SUN RAY DRUG, LLC	142 S 52ND STREET		PHILADELPHIA	PA	19139	01/01/2024
CH034140	SUNRAY DRUGS PROGRESS PLAZA	1501 N BROAD ST STE 9		PHILADELPHIA	PA	19122	01/01/2019
CH03414A	SUNRAY DRUGS PROGRESS PLAZA	1501 N BROAD ST STE 9		PHILADELPHIA	PA	19122	07/01/2019
CH03414B	SUNRAY DRUGS PROGRESS PLAZA	1501 N BROAD ST STE 9		PHILADELPHIA	PA	19122	07/01/2019
CH034140	SUNRAY DRUGS SPECIALTY	142 S 52ND ST	SUITE 201	PHILADELPHIA	PA	19139	10/01/2020
CH03414A	SUNRAY DRUGS SPECIALTY	142 S 52ND ST	SUITE 201	PHILADELPHIA	PA	19139	01/01/2024
CH03414B	SUNRAY DRUGS SPECIALTY	142 S 52ND ST	SUITE 201	PHILADELPHIA	PA	19139	01/01/2024
CH03414C	SUNRAY DRUGS SPECIALTY	142 S 52ND ST	SUITE 201	PHILADELPHIA	PA	19139	01/01/2024
CH034140	THRIFT DRUG, INC.	RITE AID #11122	284 EAST LANCASTER AVENUE	WYNNEWOOD	PA	19096	07/01/2025
CH03414A	THRIFT DRUG, INC.	RITE AID #11130	7700 CRITTENDEN STREET SUITE 101C	PHILADELPHIA	PA	19118	07/01/2025
CH03414A	THRIFT DRUG, INC.	RITE AID #11122	284 EAST LANCASTER AVENUE	WYNNEWOOD	PA	19096	07/01/2025
CH03414C	THRIFT DRUG, INC.	RITE AID #11130	7700 CRITTENDEN STREET SUITE 101C	PHILADELPHIA	PA	19118	07/01/2025
CH03414C	THRIFT DRUG, INC.	RITE AID #11122	284 EAST LANCASTER AVENUE	WYNNEWOOD	PA	19096	07/01/2025
CH03414B	THRIFT DRUG, INC.	RITE AID #11105	832 NORTH LANSDOWNE AVE.	DREXEL HILL	PA	19026	07/01/2025
CH03414B	THRIFT DRUG, INC.	RITE AID #11122	284 EAST LANCASTER AVENUE	WYNNEWOOD	PA	19096	07/01/2025
CH034140	THRIFT DRUG, INC.	RITE AID #11105	832 NORTH LANSDOWNE AVE.	DREXEL HILL	PA	19026	07/01/2025
CH03414A	THRIFT DRUG, INC.	RITE AID #11105	832 NORTH LANSDOWNE AVE.	DREXEL HILL	PA	19026	07/01/2025
CH03414C	THRIFT DRUG, INC.	RITE AID #11105	832 NORTH LANSDOWNE AVE.	DREXEL HILL	PA	19026	07/01/2025
CH034140	THRIFT DRUG, INC.	RITE AID #11130	7700 CRITTENDEN STREET SUITE 101C	PHILADELPHIA	PA	19118	07/01/2025
CH03414B	THRIFT DRUG, INC.	RITE AID #11130	7700 CRITTENDEN STREET SUITE 101C	PHILADELPHIA	PA	19118	07/01/2025
CH034140	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/01/2019	07/08/2019
CH03414B	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/01/2019	07/08/2019
CH034140	WAL-MART PHARMACY 10-2040	2106 MT HOLLY RD		BURLINGTON	NJ	08016	01/01/2019	07/08/2019
CH03414A	WAL-MART PHARMACY 10-2040	2106 MT HOLLY RD		BURLINGTON	NJ	08016	07/01/2019	07/08/2019
CH03414B	WAL-MART PHARMACY 10-2040	2106 MT HOLLY RD		BURLINGTON	NJ	08016	07/01/2019	07/08/2019
CH034140	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/01/2019	07/08/2019
CH03414A	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/01/2019	07/08/2019
CH03414A	WALMART PHARMACY 10-3585	2901 RILEY FUZZELL RD		SPRING	TX	77386	07/01/2019	07/08/2019

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	2/23/2024 3:51:24 PM	2/13/2025 12:33:04 PM	2/13/2025 12:33 PM
Contacts	Authorizing Official	Update	Profile Change Request	Russell-Young, Shawna L VP, Compliance Spectrum Health Services, Inc 2156680847	Russell-Young, Shawna L Chief Compliance Officer Spectrum Health Services, Inc 2156680847	7/8/2024 8:02 AM
Contacts	Primary Contact	Update	Change Request	Graves, Karen L Chief Financial Officer Spectrum Health Services, Inc. 2159363118	Brown, Suzanne Director of Pharmacy Services Spectrum Health Services, Inc. 2677692512	7/3/2024 11:49 AM
Details	Last Recertification Date	Update	Recertification	2/21/2023 3:23:12 PM	2/23/2024 3:51:24 PM	2/23/2024 3:51 PM
Contacts	Primary Contact	Update		Graves, Karen Chief Financial Officer Spectrum Health Services, Inc. 2159363118	Graves, Karen L Chief Financial Officer Spectrum Health Services, Inc. 2159363118	10/6/2023 1:07 PM
Contacts	Primary Contact	Update	Change Request	DeMilio, David B. Chief Financial Officer Spectrum Health Services, Inc. 2154712920	Graves, Karen Chief Financial Officer Spectrum Health Services, Inc. 2159363118	10/5/2023 5:36 PM
Details	Last Recertification Date	Update	Recertification	2/22/2022 4:20:25 PM	2/21/2023 3:23:12 PM	2/21/2023 3:23 PM
Details	Last Recertification Date	Update	Recertification	2/18/2021 2:29:28 PM	2/22/2022 4:20:25 PM	2/22/2022 4:20 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1881629012 ( )		2/18/2021 2:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1881629012	2/18/2021 2:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	2/18/2021 2:29 PM
Details	Last Recertification Date	Update	Recertification	2/18/2020 3:16:47 PM	2/18/2021 2:29:28 PM	2/18/2021 2:29 PM
Contacts	Authorizing Official	Update	Change Request	Graves, Karen L Chief Compliance Officer Spectrum Health Services 2679905338-2014179086	Russell-Young, Shawna L VP, Compliance Spectrum Health Services, Inc 2156680847	11/18/2020 7:14 AM
Contacts	Primary Contact	Update	Change Request	Pendelton, Robyn 340B Program Manager Spectrum Health Services, Inc. 2678963957	DeMilio, David B. Chief Financial Officer Spectrum Health Services, Inc. 2154712920	7/22/2020 6:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/8/2020 2:03 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007288260005	7/8/2020 2:03 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	7/8/2020 2:03 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1881629012	7/8/2020 2:03 PM
Contacts	Authorizing Official	Update	Change Request	Graves, Karen L Chief Compliance Officer Spectrum Health Services 2679905338	Graves, Karen L Chief Compliance Officer Spectrum Health Services 2679905338-2014179086	6/16/2020 2:14 PM
Contacts	Authorizing Official	Update	Profile Change Request	Graves, Karen L Chief Compliance Officer Spectrum Health Services 2679905338-2014179086	Graves, Karen L Chief Compliance Officer Spectrum Health Services 2679905338	6/2/2020 2:21 PM
Contacts	Primary Contact	Update	Change Request	DeMilio, David B. Chief Financial Officer Spectrum Health Services, Inc. 2154712920	Pendelton, Robyn 340B Program Manager Spectrum Health Services, Inc. 2678963957	5/13/2020 10:52 AM
Contacts	Authorizing Official	Update	Change Request	Graves, Karen L Chief Compliance Officer Spectrum Health Services 2679905338	Graves, Karen L Chief Compliance Officer Spectrum Health Services 2679905338-2014179086	5/13/2020 10:46 AM
Contacts	Authorizing Official	Update	AO Change Request	Enakhimion, Yahaya Ehigie Chief Operating Officer Spectrum Health Services, Inc. 2677694896	Graves, Karen L Chief Compliance Officer Spectrum Health Services 2679905338	5/11/2020 2:09 PM
Details	Last Recertification Date	Update	Recertification	2/22/2019 8:34:06 AM	2/18/2020 3:16:47 PM	2/18/2020 3:16 PM
Contacts	Authorizing Official	Update	Change Request	Wroten, Stephanie Chief Programs and Develop Spectrum Health Services Inc 2154712761-3256	Enakhimion, Yahaya Ehigie Chief Operating Officer Spectrum Health Services, Inc. 2677694896	11/15/2019 12:51 PM
Contacts	Primary Contact	Update	Recertification	Emmanuel, Yvonne T. Director of Administrative Services Spectrum Health Services, Inc. 2154712756	DeMilio, David B. Chief Financial Officer Spectrum Health Services, Inc. 2154712920	2/22/2019 8:34 AM
Details	Last Recertification Date	Update	Recertification	3/5/2018 1:35:04 PM	2/22/2019 8:34:06 AM	2/22/2019 8:34 AM
Contacts	Authorizing Official	Update	AO Change Request	Cater, Phyllis B. President & CEO Spectrum Health Services, Inc. 2154712755	Wroten, Stephanie Chief Programs and Develop Spectrum Health Services Inc 2154712761-3256	2/22/2019 7:21 AM
Contacts	Primary Contact	Update	Recertification	Haynes, Curtis CFO 2154712924	Emmanuel, Yvonne T. Director of Administrative Services Spectrum Health Services, Inc. 2154712756	3/5/2018 1:35 PM
Details	Last Recertification Date	Update	Recertification	2/6/2017 12:00:00 AM	3/5/2018 1:35:04 PM	3/5/2018 1:35 PM
Details	Is Authorizing Official EHB Data	Update	Recertification	False		3/5/2018 1:35 PM
Contacts	Authorizing Official	Update		Cater, Phyllis B. President & CEO 2154712755	Cater, Phyllis B. President & CEO Spectrum Health Services, Inc. 2154712755	2/9/2018 3:35 PM
Contacts	Signed By	Update		Cater, Phyllis B. President & CEO 2154712755	Cater, Phyllis B. President & CEO Spectrum Health Services, Inc. 2154712755	2/9/2018 3:35 PM
Contacts	Authorizing Official	Insert			Cater, Phyllis B. President & CEO 2154712755	5/12/2017 12:21 PM
Contacts	Signed By	Insert			Cater, Phyllis B. President & CEO 2154712755	5/12/2017 12:21 PM
Contacts	Primary Contact	Insert			Haynes, Curtis CFO 2154712924	2/6/2017 1:21 PM
Addresses	Main Address	Insert			1415 N Broad St STE 224 Philadelphia, PA 19122-3325	2/6/2017 1:21 PM
Details	Last Recertification Date	Update			2/6/2017 12:00:00 AM	2/6/2017 1:20 PM
Addresses	Billing Address	Insert			Spectrum Health Services, Inc 5201 Haverford Avenue Philadelphia, PA 19139	7/21/2016 11:52 AM
Dates	Participating Approval Date	Update			7/21/2016 12:00:00 AM	7/21/2016 11:52 AM
Details	State	Update		Pending	Active	7/21/2016 11:52 AM
Dates	Start Date	Update			10/1/2016 12:00:00 AM	7/21/2016 11:52 AM
Details	340B ID	Update		ONLINE_REG_71524	CH03414A	7/20/2016 10:30 AM
Details	340B ID	Update		ONLINE_REG	ONLINE_REG_71524	7/13/2016 11:08 AM
Details	Last Recertification Date	Insert				7/13/2016 11:08 AM
Details	Grant Number	Insert			H80CS00389	7/13/2016 11:08 AM
Details	340B ID	Insert			ONLINE_REG	7/13/2016 11:08 AM
Details	Is Authorizing Official EHB Data	Insert			False	7/13/2016 11:08 AM
Dates	Last Date That 340B Drugs Purchased	Insert				7/13/2016 11:08 AM
Details	Medicare Provider Number	Insert				7/13/2016 11:08 AM
Details	Entity Name	Insert			SPECTRUM HEALTH SERVICES, INC.	7/13/2016 11:08 AM
Details	Program Code	Insert			CH	7/13/2016 11:08 AM
Details	Entity Subname	Insert			BROAD STREET HEALTH CENTER	7/13/2016 11:08 AM
Dates	Participating Approval Date	Insert				7/13/2016 11:08 AM
Details	State	Insert			Pending	7/13/2016 11:08 AM
Dates	Registration Date	Insert			7/13/2016 12:00:00 AM	7/13/2016 11:08 AM
Dates	Signed By Date	Insert			7/13/2016 12:00:00 AM	7/13/2016 11:08 AM
Dates	Start Date	Insert				7/13/2016 11:08 AM
Terminations	Termination Comments	Insert				7/13/2016 11:08 AM
Terminations	Termination Date	Insert				7/13/2016 11:08 AM
Terminations	Termination Effective Date	Insert				7/13/2016 11:08 AM
Terminations	Termination Reason	Insert				7/13/2016 11:08 AM

340B Drug Pricing Program Database