Covered Entity Details

FQHCLA328F SAN JOAQUIN, COUNTY OF (Terminated) - information as of 5/10/2025 10:49:56 PM

Main Details

Name

SAN JOAQUIN, COUNTY OF

Subdivision Name

Hazelton Clinic

Type

Health Center Program Look-Alike

Site ID

BPS-LAL-019320

340B ID

FQHCLA328F

Grant Number

LALCS00158

Additional Details

Current Program Status

Terminated

Registration Date

4/5/2017

Participating Start Date

7/1/2017

Participating Approval Date

4/18/2017

Last Recertification Date

1/28/2020

Termination Date
Termination Reason

4/1/2021
Site closure

Contacts

Authorizing Official

San Joaquin County Clinics
Farhan Fadoo, Chief Executive Officer
(209) 953-3700

Primary Contact

San Joaquin County Clinics
Betty Jo Riendel, Clinic Nursing Manager
(209) 468-6177

Addresses

Street Address

1601 E. Hazelton Ave
Stockton, CA 95205

Billing Address
Same as Street Address

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

Comments

Comment	Last Updated On
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
		1679023980

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
FQHCLA328	Active	BPS-LAL-014288	SAN JOAQUIN, COUNTY OF	Primary Medicine Clinic	500 W. Hospital Rd	French Camp	CA
FQHCLA328A	Active	BPS-LAL-014287	SAN JOAQUIN, COUNTY OF	Healthy Beginnings California	1414 N California St Ste B	Stockton	CA
FQHCLA328B	Active	BPS-LAL-014286	SAN JOAQUIN, COUNTY OF	Healthy Beginnings French Camp	500 W Hospital Rd	French Camp	CA
FQHCLA328C	Active	BPS-LAL-014285	SAN JOAQUIN, COUNTY OF	Family Practice Clinic California	1414 N CALIFORNIA ST	STOCKTON	CA
FQHCLA328D	Active	BPS-LAL-014284	SAN JOAQUIN, COUNTY OF	Family Medicine Clinic	500 W Hospital Rd	French Camp	CA
FQHCLA328E	Active	BPS-LAL-014283	SAN JOAQUIN, COUNTY OF	Children's Health Services	1414 N California St	Stockton	CA
FQHCLA328F	Terminated	BPS-LAL-019320	SAN JOAQUIN, COUNTY OF	Hazelton Clinic	1601 E. Hazelton Ave	Stockton	CA
FQHCLA328G	Terminated	BPS-LAL-020767	SAN JOAQUIN, COUNTY OF	Manteca Clinic	283 Spreckels Avenue	Manteca	CA
FQHCLA328H	Active	BPS-LAL-034275	COUNTY OF SAN JOAQUIN	Mobile Clinic #1	500 W Hospital Rd	French Camp	CA
FQHCLA328J	Active	BPS-LAL-035785	COUNTY OF SAN JOAQUIN	Manteca Clinic	283 Spreckels Ave	Manteca	CA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
FQHCLA328A	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	07/01/2025
FQHCLA328J	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	07/01/2025
FQHCLA328H	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	07/01/2025
FQHCLA328B	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	07/01/2025
FQHCLA328D	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	07/01/2025
FQHCLA328E	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	07/01/2025
FQHCLA328	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	07/01/2025
FQHCLA328C	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	07/01/2025
FQHCLA328J	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/01/2025
FQHCLA328A	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/01/2025
FQHCLA328E	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/01/2025
FQHCLA328D	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/01/2025
FQHCLA328C	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/01/2025
FQHCLA328	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/01/2025
FQHCLA328H	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/01/2025
FQHCLA328B	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/01/2025
FQHCLA328C	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/01/2025
FQHCLA328B	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/01/2025
FQHCLA328A	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/01/2025
FQHCLA328J	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/01/2025
FQHCLA328	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/01/2025
FQHCLA328E	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/01/2025
FQHCLA328D	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/01/2025
FQHCLA328H	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/01/2025
FQHCLA328H	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/01/2025
FQHCLA328J	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/01/2025
FQHCLA328B	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/01/2025
FQHCLA328D	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/01/2025
FQHCLA328C	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/01/2025
FQHCLA328	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/01/2025
FQHCLA328E	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/01/2025
FQHCLA328A	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/01/2025
FQHCLA328B	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/01/2025
FQHCLA328C	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/01/2025
FQHCLA328J	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/01/2025
FQHCLA328H	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/01/2025
FQHCLA328E	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/01/2025
FQHCLA328D	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/01/2025
FQHCLA328A	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/01/2025
FQHCLA328	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/01/2025
FQHCLA328A	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/01/2025
FQHCLA328	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/01/2025
FQHCLA328E	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/01/2025
FQHCLA328C	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/01/2025
FQHCLA328B	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/01/2025
FQHCLA328J	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/01/2025
FQHCLA328H	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/01/2025
FQHCLA328D	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/01/2025
FQHCLA328H	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/01/2025
FQHCLA328B	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/01/2025
FQHCLA328A	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/01/2025
FQHCLA328C	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/01/2025
FQHCLA328	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/01/2025
FQHCLA328J	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/01/2025
FQHCLA328D	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/01/2025
FQHCLA328E	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/01/2025
FQHCLA328	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/01/2025
FQHCLA328B	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/01/2025
FQHCLA328A	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/01/2025
FQHCLA328J	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/01/2025
FQHCLA328C	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/01/2025
FQHCLA328D	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/01/2025
FQHCLA328H	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/01/2025
FQHCLA328E	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/01/2025
FQHCLA328E	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/01/2025
FQHCLA328C	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/01/2025
FQHCLA328J	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/01/2025
FQHCLA328	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/01/2025
FQHCLA328H	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/01/2025
FQHCLA328A	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/01/2025
FQHCLA328D	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/01/2025
FQHCLA328B	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/01/2025
FQHCLA328A	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/01/2025
FQHCLA328D	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/01/2025
FQHCLA328B	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/01/2025
FQHCLA328H	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/01/2025
FQHCLA328	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/01/2025
FQHCLA328J	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/01/2025
FQHCLA328E	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/01/2025
FQHCLA328C	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/01/2025
FQHCLA328E	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/01/2025
FQHCLA328D	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/01/2025
FQHCLA328	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/01/2025
FQHCLA328C	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/01/2025
FQHCLA328B	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/01/2025
FQHCLA328A	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/01/2025
FQHCLA328H	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/01/2025
FQHCLA328J	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/01/2025
FQHCLA328D	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/01/2025
FQHCLA328J	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/01/2025
FQHCLA328H	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/01/2025
FQHCLA328B	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/01/2025
FQHCLA328E	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/01/2025
FQHCLA328A	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/01/2025
FQHCLA328	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/01/2025
FQHCLA328C	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/01/2025
FQHCLA328	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16223	2800 NAGLEE RD	TRACY	CA	95304	04/01/2023
FQHCLA328	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 05403	1175 W. LATHROP RD.	MANTECA	CA	95336	04/01/2023
FQHCLA328	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17412	16858 GOLDEN VALLEY PKWY	LATHROP	CA	95330	04/01/2023
FQHCLA328	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 02994	3100 GEER RD.	TURLOCK	CA	95382	04/01/2023
FQHCLA328	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16856	280 SPRECKELS AVE	MANTECA	CA	95336	04/01/2023
FQHCLA328	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16107	4707 PACIFIC AVE	STOCKTON	CA	95207	04/01/2023
FQHCLA328	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16982	10424 TRINITY PARKWAY	STOCKTON	CA	95219	04/01/2023
FQHCLA328	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09866	1190 N MAIN ST	MANTECA	CA	95336	04/01/2023
FQHCLA328	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 03908	1885 W 11TH ST	TRACY	CA	95376	04/01/2023
FQHCLA328	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09248	1700 MCHENRY AVE.	MODESTO	CA	95350	04/01/2023
FQHCLA328	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09874	2075 E HATCH ROAD	MODESTO	CA	95351	04/01/2023
FQHCLA328	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09243	1000 W KETTLEMAN LN	LODI	CA	95240	04/01/2023
FQHCLA328	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09830	6632 PACIFIC AVENUE	STOCKTON	CA	95207	04/01/2023
FQHCLA328	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09147	2605 WEST MARCH LANE	STOCKTON	CA	95207	04/01/2023
FQHCLA328	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 03077	801 OAKDALE RD STE F	MODESTO	CA	95355	04/01/2023
FQHCLA328	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09261	100 W LODI AVE	LODI	CA	95240	04/01/2023
FQHCLA328	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09855	3320 N TRACY BLVD	TRACY	CA	95376	04/01/2023
FQHCLA328	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09949	1201 W MAIN ST STE 14	RIPON	CA	95366	04/01/2023
FQHCLA328A	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/01/2025
FQHCLA328H	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/01/2025
FQHCLA328D	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/01/2025
FQHCLA328	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/01/2025
FQHCLA328C	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/01/2025
FQHCLA328E	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/01/2025
FQHCLA328B	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/01/2025
FQHCLA328J	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/01/2025
FQHCLA328C	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/01/2025
FQHCLA328	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/01/2025
FQHCLA328H	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/01/2025
FQHCLA328A	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/01/2025
FQHCLA328J	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/01/2025
FQHCLA328J	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/01/2025
FQHCLA328B	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/01/2025
FQHCLA328	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/01/2025
FQHCLA328H	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/01/2025
FQHCLA328E	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/01/2025
FQHCLA328E	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/01/2025
FQHCLA328C	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/01/2025
FQHCLA328D	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/01/2025
FQHCLA328A	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/01/2025
FQHCLA328B	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/01/2025
FQHCLA328D	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/01/2025
FQHCLA328	SAFEWAY INC	SAFEWAY PHARMACY #1769	2808 COUNTRY CLUB BLVD	STOCKTON	CA	95204	06/01/2020
FQHCLA328	SAN JOAQUIN GEN HOSP	500 W HOSPITAL RD		FRENCH CAMP	CA	95231	01/01/2015	07/31/2024
FQHCLA328A	SAN JOAQUIN GEN HOSP	500 W HOSPITAL RD		FRENCH CAMP	CA	95231	01/01/2015	07/31/2024
FQHCLA328B	SAN JOAQUIN GEN HOSP	500 W HOSPITAL RD		FRENCH CAMP	CA	95231	01/01/2015	07/31/2024
FQHCLA328C	SAN JOAQUIN GEN HOSP	500 W HOSPITAL RD		FRENCH CAMP	CA	95231	01/01/2015	07/31/2024
FQHCLA328D	SAN JOAQUIN GEN HOSP	500 W HOSPITAL RD		FRENCH CAMP	CA	95231	01/01/2015	07/31/2024
FQHCLA328E	SAN JOAQUIN GEN HOSP	500 W HOSPITAL RD		FRENCH CAMP	CA	95231	01/01/2015	07/31/2024
FQHCLA328	THRIFTY PAYLESS, INC.	RITE AID #6434	1710 CALIFORNIA ST RITE AID 6434	ESCALON	CA	95320	06/01/2020
FQHCLA328	THRIFTY PAYLESS, INC.	RITE AID #5996	1050 NORTH WILSON WAY	STOCKTON	CA	95205	06/01/2020
FQHCLA328	THRIFTY PAYLESS, INC.	RITE AID #6000	520 WEST LODI AVENUE	LODI	CA	95240	06/01/2020
FQHCLA328	THRIFTY PAYLESS, INC.	RITE AID #5998	6455 PACIFIC AVENUE	STOCKTON	CA	95207	06/01/2020
FQHCLA328	THRIFTY PAYLESS, INC.	RITE AID #6005	1245 WEST YOSEMITE AVENUE	MANTECA	CA	95337	06/01/2020
FQHCLA328	THRIFTY PAYLESS, INC.	RITE AID #6291	1970 WEST GRANTLINE ROAD	TRACY	CA	95376	06/01/2020	01/01/2024
FQHCLA328	THRIFTY PAYLESS, INC.	RITE AID #6510	4774 WEST LANE	STOCKTON	CA	95210	06/01/2020
FQHCLA328	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	06/01/2020
FQHCLA328	WAL-MART PHARMACY 10-1554	3223 EAST HAMMER LANE		STOCKTON	CA	95212	06/01/2020
FQHCLA328	WAL-MART PHARMACY 10-1789	1601 S. LOWER SACRAMENTO RD.		LODI	CA	95242	06/01/2020	11/26/2023
FQHCLA328	WAL-MART PHARMACY 10-1840	1205 S. MAIN STREET		MANTECA	CA	95337	06/01/2020
FQHCLA328	WAL-MART PHARMACY 10-2025	3010 WEST GRANT LINE ROAD		TRACY	CA	95304	06/01/2020	11/26/2023
FQHCLA328	WAL-MART PHARMACY 10-3022	1189 E MARCH LANE		STOCKTON	CA	95210	06/01/2020
FQHCLA328	WAL-MART PHARMACY 10-3352	10355 TRINITY PKWY		STOCKTON	CA	95219	06/01/2020
FQHCLA328	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	06/01/2020
FQHCLA328	WALGREEN CO	DBA: WALGREENS #10631	14780 S HARLAN RD	LATHROP	CA	95330	06/01/2020
FQHCLA328	WALGREEN CO	DBA: WALGREENS #10482	7850 WEST LANE	STOCKTON	CA	95210	06/01/2020
FQHCLA328	WALGREEN CO.	DBA: WALGREENS # 02680	15 W HARDING WAY	STOCKTON	CA	95204	06/01/2020
FQHCLA328	WALGREEN CO.	DBA: WALGREENS #13984	1528 E FREMONT ST	STOCKTON	CA	95205	06/01/2020
FQHCLA328	WALGREEN CO.	DBA: WALGREENS # 02770	7929 LOWER SACRAMENTO RD.	STOCKTON	CA	95210	06/01/2020
FQHCLA328	WALGREEN CO.	DBA: WALGREENS #12549	2040 E. MARIPOSA RD.	STOCKTON	CA	95205-7736	06/01/2020
FQHCLA328	WALGREEN CO.	DBA: WALGREENS # 10454	1071 N MAIN ST	MANTECA	CA	95336	06/01/2020
FQHCLA328	WALGREEN CO.	DBA: WALGREENS #15398	660 W. MARCH LANE	STOCKTON	CA	95207	06/01/2020
FQHCLA328	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/01/2023
FQHCLA328	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Fadoo, Farhan Chief Executive Officer San Joaquin Clinics 2094685623	Fadoo, Farhan Chief Executive Officer San Joaquin County Clinics 2099533700	4/18/2023 6:42 AM
Details	State	Update		To Be Terminated	Terminated	4/1/2021 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		6/30/2020 12:00:00 AM	2/9/2021 4:38 PM
Details	State	Update	Recertification	Active	To Be Terminated	2/9/2021 4:38 PM
Terminations	Termination Date	Update	Recertification		4/1/2021 12:00:00 AM	2/9/2021 4:38 PM
Terminations	Termination Effective Date	Update	Recertification		6/30/2020 12:00:00 AM	2/9/2021 4:38 PM
Terminations	Termination Reason	Update	Recertification		Site closure	2/9/2021 4:38 PM
Details	Last Recertification Date	Update	Recertification	2/1/2019 12:31:31 PM	1/28/2020 3:22:23 PM	1/28/2020 3:22 PM
Contacts	Authorizing Official	Update	Change Request	Wiesen, Chuck CEO San Joaquin County Clinics 2094686160	Fadoo, Farhan Chief Executive Officer San Joaquin Clinics 2094685623	8/7/2019 10:53 AM
Details	Last Recertification Date	Update	Recertification	2/7/2018 5:08:54 PM	2/1/2019 12:31:31 PM	2/1/2019 12:31 PM
Contacts	Authorizing Official	Update	Change Request	Fadoo, Farhan Chief Medical Officer San Joaquin Clinics 2094685623	Wiesen, Chuck CEO San Joaquin County Clinics 2094686160	12/19/2018 7:10 AM
Details	Last Recertification Date	Update	Recertification		2/7/2018 5:08:54 PM	2/7/2018 5:08 PM
Details	Grant Number	Update	Recertification	LAL000158	LALCS00158	2/7/2018 5:08 PM
Contacts	Primary Contact	Update	Change Request	Szczepaniak, Margaret Asst Director HCS 2094686672	Riendel, Betty Jo Clinic Nursing Manager San Joaquin County Clinics 2094686177	12/20/2017 10:40 AM
Contacts	Authorizing Official	Update	Change Request	Jomaoas, David B. Executive Director San Joaquin County Clinics 2094686160	Fadoo, Farhan Chief Medical Officer San Joaquin Clinics 2094685623	12/20/2017 10:40 AM
Details	Is Authorizing Official EHB Data	Update	Change Request	False		12/20/2017 10:40 AM
Contacts	Authorizing Official	Update		Jomaoas, David B. Executive Director 2094686160	Jomaoas, David B. Executive Director San Joaquin County Clinics 2094686160	12/14/2017 5:26 PM
Contacts	Signed By	Update		Jomaoas, David B. Executive Director 2094686160	Jomaoas, David B. Executive Director San Joaquin County Clinics 2094686160	12/14/2017 5:26 PM
Contacts	Authorizing Official	Insert			Jomaoas, David B. Executive Director 2094686160	7/14/2017 1:10 PM
Contacts	Signed By	Insert			Jomaoas, David B. Executive Director 2094686160	7/14/2017 1:10 PM
Addresses	Main Address	Insert			1601 E. Hazelton Ave Stockton, CA 95205	5/16/2017 1:03 PM
Contacts	Primary Contact	Insert			Szczepaniak, Margaret Asst Director HCS 2094686672	5/16/2017 1:03 PM
Dates	Participating Approval Date	Update			4/18/2017 12:00:00 AM	4/18/2017 6:09 PM
Details	State	Update		Pending	Active	4/18/2017 6:09 PM
Dates	Start Date	Update			7/1/2017 12:00:00 AM	4/18/2017 6:09 PM
Details	340B ID	Update		FQHCLA350	FQHCLA328F	4/18/2017 9:58 AM
Details	340B ID	Update		FQHCLA349	FQHCLA350	4/10/2017 10:43 AM
Details	340B ID	Update		ONLINE_REG_76079	FQHCLA349	4/10/2017 10:38 AM
Details	340B ID	Update		ONLINE_REG	ONLINE_REG_76079	4/5/2017 7:59 PM
Medicaid Billing	NPI: Number	Insert			1679023980	4/5/2017 7:59 PM
Details	Last Recertification Date	Insert				4/5/2017 7:59 PM
Details	Grant Number	Insert			LAL000158	4/5/2017 7:59 PM
Details	340B ID	Insert			ONLINE_REG	4/5/2017 7:59 PM
Details	Is Authorizing Official EHB Data	Insert			False	4/5/2017 7:59 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/5/2017 7:59 PM
Details	Medicare Provider Number	Insert				4/5/2017 7:59 PM
Details	Entity Name	Insert			SAN JOAQUIN, COUNTY OF	4/5/2017 7:59 PM
Details	Program Code	Insert			FQHCLA	4/5/2017 7:59 PM
Details	Entity Subname	Insert			Hazelton Clinic	4/5/2017 7:59 PM
Dates	Participating Approval Date	Insert				4/5/2017 7:59 PM
Details	State	Insert			Pending	4/5/2017 7:59 PM
Dates	Registration Date	Insert			4/5/2017 12:00:00 AM	4/5/2017 7:59 PM
Dates	Signed By Date	Insert			4/5/2017 12:00:00 AM	4/5/2017 7:59 PM
Dates	Start Date	Insert				4/5/2017 7:59 PM
Terminations	Termination Comments	Insert				4/5/2017 7:59 PM
Terminations	Termination Date	Insert				4/5/2017 7:59 PM
Terminations	Termination Effective Date	Insert				4/5/2017 7:59 PM
Terminations	Termination Reason	Insert				4/5/2017 7:59 PM

340B Drug Pricing Program Database