Covered Entity Details

CHC26592-01 COASTAL COMMUNITY HEALTH SERVICES, INC. (Terminated) - information as of 6/16/2025 11:22:43 PM

Main Details

Name

COASTAL COMMUNITY HEALTH SERVICES, INC.

Subdivision Name

Perry Park

Type

HRSA-Funded Health Center

Site ID

BPS-H80-018961

340B ID

CHC26592-01

Grant Number

H80CS26592

Additional Details

Current Program Status

Terminated

Registration Date

4/14/2017

Participating Start Date

7/1/2017

Participating Approval Date

4/24/2017

Last Recertification Date

1/31/2022

Termination Date
Termination Reason

1/1/2023
Site closure

Contacts

Authorizing Official

Coastal Community Health Services
Kavanaugh Chandler, CEO
(912) 275-8028 Ext: 1139

Primary Contact

Coastal Community Health Services, Inc.
Martina Senol, CFO
(912) 275-8028 Ext: 111

Addresses

Street Address

2211 Bartow Street
Brunswick, GA 31520-5604

Billing Address

Coastal Community Health Services, INC.
106 Shoppers Way
Suite 1
Brunswick, GA 31525

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?
No

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	CURANT HEALTH FLORIDA, LLC	11001 ROOSEVELT BLVD N STE 1400		ST PETERSBURG	FL	33716	07/17/2017	10/01/2017	09/30/2021	10/06/2021
Contract Detail	CURANT HEALTH GEORGIA LLC	CURANT HEALTH	200 TECHNOLOGY CT SE BLDG 200 SUITE B	SMYRNA	GA	30082-5250	07/03/2017	10/01/2017	09/30/2021	10/06/2021
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04567	5421 NEW JESUP HWY.	BRUNSWICK	GA	31523	07/08/2021	10/01/2021	09/30/2021	10/06/2021
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04337	30 MARKET STREET	SAINT SIMONS ISLAND	GA	31522	07/08/2021	10/01/2021	09/30/2021	10/06/2021
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	CVS PHARMACY # 17369	200 GLYNN ISLE	BRUNSWICK	GA	31525	07/08/2021	10/01/2021	09/30/2021	10/06/2021
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04575	1605 FREDERICA ROAD	SAINT SIMONS ISLAND	GA	31522	07/08/2021	10/01/2021	09/30/2021	10/06/2021
Contract Detail	GOLDEN ISLES PHARMACY	DONATO HEALTH, LLC	3010 ALTAMA AVE	BRUNSWICK	GA	31520-4607	10/12/2018	01/01/2019	09/30/2021	10/06/2021
Contract Detail	JETS PHARMACY LLC	1229 NORTH WAY		DARIEN	GA	31305	07/15/2021	10/01/2021	09/30/2021	10/06/2021
Contract Detail	SAMSON MERGER SUB, LLC	WINN DIXIE #67	341 VENTURE DRIVE	BRUNSWICK	GA	31525	04/14/2019	07/01/2019	09/30/2021	10/06/2021
Contract Detail	SAMSON MERGER SUB, LLC	WINN DIXIE #68	284 HYDE PARK COMMONS	BRUNSWICK	GA	31523	04/14/2019	07/01/2019	09/30/2021	10/06/2021
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/10/2020	04/01/2020	09/30/2021	10/06/2021
Contract Detail	WAL-MART PHARMACY 10-0639	150 ALTAMA CONNECTOR		BRUNSWICK	GA	31525	10/12/2018	01/01/2019	09/30/2021	10/06/2021
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/10/2020	04/01/2020	09/30/2021	10/06/2021
Contract Detail	WALGREEN CO	DBA: WALGREENS #10266	101 TORRAS DRIVE	BRUNSWICK	GA	31520	07/03/2017	10/01/2017	09/30/2021	10/06/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07848	4575 ALTAMA AVE	BRUNSWICK	GA	31520	07/03/2017	10/01/2017	09/30/2021	10/06/2021
Contract Detail	WALMART PHARMACY #10-2840	11 GLYNN PLAZA		BRUNSWICK	GA	31520	10/12/2018	01/01/2019	09/30/2021	10/06/2021
Contract Detail	WINN DIXIE PHARMACY # 19	220 RETREAT VILLAGE		SAINT SIMONS ISLAND	GA	31522	04/14/2019	07/01/2019	09/30/2021	10/06/2021

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CHC26592-00	Active	BPS-H80-013664	Coastal Community Health Services, Inc.	Coastal Community Health Services	106 Shoppers Way, Unit 1	Brunswick	GA
CHC26592-01	Terminated	BPS-H80-018961	COASTAL COMMUNITY HEALTH SERVICES, INC.	Perry Park	2211 Bartow Street	Brunswick	GA
CHC26592-02	Active	BPS-H80-018957	COASTAL COMMUNITY HEALTH SERVICES, INC.	McIntosh Center	6574 Shellman Bluff Road, NE	Townsend	GA
CHC26592-03	Active	BPS-H80-031536	Coastal Community Health Services, Inc.	CCHS Mobile Clinic	106 Shoppers Way Ste 1	Brunswick	GA
CHC26592-04	Active	BPS-H80-034182	Coastal Community Health Services, Inc.	CCHS Townsend	1299 Ga Highway 57	Townsend	GA
CHC26592-05	Active	BPS-H80-035210	COASTAL COMMUNITY HEALTH SERVICES, INC.	CCHS Downtown Brunswick	1600 Ellis St	Brunswick	GA
CHC26592-06	Active	BPS-H80-036259	COASTAL COMMUNITY HEALTH SERVICES, INC.	CCHS St. Mary’s	202 Lakeshore Dr	St Marys	GA
CHC26592-07	Active	BPS-H80-036499	COASTAL COMMUNITY HEALTH SERVICES, INC.	CCHS Darien	1022 Miller Ln SW	Darien	GA
CHC26592-08	Active	BPS-H80-037181	COASTAL COMMUNITY HEALTH SERVICES, INC.	CCHS Richmond Hill	10055 Ford Ave, Ste 4A	Richmond Hill	GA
CHC26592-09	Active	BPS-H80-038317	COASTAL COMMUNITY HEALTH SERVICES, INC.	CCH – Woodbine	308 Bedell Ave	Woodbine	GA
CHC26592-10	Active	BPS-H80-037454	COASTAL COMMUNITY HEALTH SERVICES, INC.	Coastal Community Health TIGERS/Todd Grant Elementary School	1102 CA Devillars Rd	Darien	GA
CHC26592-11	Active	BPS-H80-038316	COASTAL COMMUNITY HEALTH SERVICES, INC.	CCH – Waynesville	21300 Highway 82 STE C	Waynesville	GA
CHC26592-12	Active	BPS-H80-038784	COASTAL COMMUNITY HEALTH SERVICES, INC.	CCH Brunswick Pediatrics	3300 4th St	Brunswick	GA
CHC26592-13	Active	BPS-H80-038792	COASTAL COMMUNITY HEALTH SERVICES, INC.	CCH St. Simons Island Pediatrics	7000 Wellness Way STE 7230	St Simons Island	GA
CHC26592-14	Active	BPS-H80-038793	COASTAL COMMUNITY HEALTH SERVICES, INC.	CCH – Pooler	2321 Pooler Pkwy STE 106-109	Pooler	GA
CHC26592-15	Active	BPS-H80-038823	COASTAL COMMUNITY HEALTH SERVICES, INC.	CCH - Fernandina/Yulee	22385 Flora Parke Xing	Fernandina Beach	FL
CHC26592-16	Approved	BPS-H80-039843	COASTAL COMMUNITY HEALTH SERVICES, INC.	Coastal Community Health - Savannah- Continuity Clinic	1107 E 66th St	Savannah	GA
CHC26592-17	Approved	BPS-H80-039610	COASTAL COMMUNITY HEALTH SERVICES, INC.	CCH – Glynn County Employee Health	2747 4th St	Brunswick	GA
CHC26592-18	Approved	BPS-H80-040027	COASTAL COMMUNITY HEALTH SERVICES, INC.	Coastal Community Health - Jacksonville (Westside)	1605 Kingsley Ave	Orange Park	FL

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CHC26592-00	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	04/01/2025
CHC26592-00	BENNETT'S HOMETOWN PHARMACY	STETSON BENNETT	26826 HWY 82	WAYNESVILLE	GA	31566-3155	04/01/2025
CHC26592-00	CAMDEN PHARMACY INC.	214-B PROFESSIONAL CIRCLE		SAINT MARYS	GA	31558	07/01/2024
CHC26592-00	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	04/01/2024
CHC26592-00	CURANT HEALTH FLORIDA, LLC	11001 ROOSEVELT BLVD N STE 1400		ST PETERSBURG	FL	33716	01/01/2015	08/01/2023
CHC26592-01	CURANT HEALTH FLORIDA, LLC	11001 ROOSEVELT BLVD N STE 1400		ST PETERSBURG	FL	33716	10/01/2017	09/30/2021
CHC26592-02	CURANT HEALTH FLORIDA, LLC	11001 ROOSEVELT BLVD N STE 1400		ST PETERSBURG	FL	33716	10/01/2017	09/30/2021
CHC26592-00	CURANT HEALTH GEORGIA LLC	CURANT HEALTH	200 TECHNOLOGY CT SE BLDG 200 SUITE B	SMYRNA	GA	30082-5250	01/01/2015	08/01/2023
CHC26592-01	CURANT HEALTH GEORGIA LLC	CURANT HEALTH	200 TECHNOLOGY CT SE BLDG 200 SUITE B	SMYRNA	GA	30082-5250	10/01/2017	09/30/2021
CHC26592-02	CURANT HEALTH GEORGIA LLC	CURANT HEALTH	200 TECHNOLOGY CT SE BLDG 200 SUITE B	SMYRNA	GA	30082-5250	07/01/2017	09/30/2021
CHC26592-00	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	10/01/2021
CHC26592-00	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	10/01/2021
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	CVS PHARMACY # 17369	200 GLYNN ISLE	BRUNSWICK	GA	31525	10/01/2021
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04567	5421 NEW JESUP HWY.	BRUNSWICK	GA	31523	10/01/2021
CHC26592-01	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04567	5421 NEW JESUP HWY.	BRUNSWICK	GA	31523	10/01/2021	09/30/2021
CHC26592-02	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04337	30 MARKET STREET	SAINT SIMONS ISLAND	GA	31522	10/01/2021	09/30/2021
CHC26592-01	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04337	30 MARKET STREET	SAINT SIMONS ISLAND	GA	31522	10/01/2021	09/30/2021
CHC26592-02	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04575	1605 FREDERICA ROAD	SAINT SIMONS ISLAND	GA	31522	10/01/2021	09/30/2021
CHC26592-02	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04567	5421 NEW JESUP HWY.	BRUNSWICK	GA	31523	10/01/2021	09/30/2021
CHC26592-01	GEORGIA CVS PHARMACY, L.L.C.	CVS PHARMACY # 17369	200 GLYNN ISLE	BRUNSWICK	GA	31525	10/01/2021	09/30/2021
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04575	1605 FREDERICA ROAD	SAINT SIMONS ISLAND	GA	31522	10/01/2021
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04337	30 MARKET STREET	SAINT SIMONS ISLAND	GA	31522	10/01/2021
CHC26592-01	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04575	1605 FREDERICA ROAD	SAINT SIMONS ISLAND	GA	31522	10/01/2021	09/30/2021
CHC26592-02	GEORGIA CVS PHARMACY, L.L.C.	CVS PHARMACY # 17369	200 GLYNN ISLE	BRUNSWICK	GA	31525	10/01/2021	09/30/2021
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04206	2700 OSBORNE RD.	SAINT MARYS	GA	31558	04/01/2023
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05737	1402 BOONE ST.	KINGSLAND	GA	31548	04/01/2023
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07783	2324 US HIGHWAY 17	RICHMOND HILL	GA	31324	01/01/2024
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	CVS/PHARMACY # 11017	500 POOLER PKWY.	POOLER	GA	31322	10/01/2024	10/01/2024
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	CVS/PHARMACY # 11017	500 POOLER PKWY.	POOLER	GA	31322	01/01/2025
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04187	119 BULL ST	SAVANNAH	GA	31401	07/01/2025
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04229	12012 ABERCORN STREET	SAVANNAH	GA	31419	07/01/2025
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04230	150 JOHNNY MERCER BLVD	SAVANNAH	GA	31410	07/01/2025
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04257	712 STEPHENSON AVE.	SAVANNAH	GA	31405	07/01/2025
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04260	4725 WATERS AVE	SAVANNAH	GA	31404	07/01/2025
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04261	2055 EAST VICTORY DR	SAVANNAH	GA	31404	07/01/2025
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05351	301 E MONTGOMERY CROSS RD	SAVANNAH	GA	31406	07/01/2025
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05520	5401 ABERCORN STREET	SAVANNAH	GA	31405	07/01/2025
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 06369	5690 OGEECHEE RD.	SAVANNAH	GA	31405	07/01/2025
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07228	7360 SKIDAWAY ROAD	SAVANNAH	GA	31406	07/01/2025
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	CVS PHARMACY # 17028	14065 ABERCORN ST	SAVANNAH	GA	31419	07/01/2025
CHC26592-00	GEORGIA CVS PHARMACY, L.L.C.	CVS PHARMACY # 17397	1907 E VICTORY DR	SAVANNAH	GA	31404	07/01/2025
CHC26592-00	GOLDEN ISLES PHARMACY	DONATO HEALTH, LLC	3010 ALTAMA AVE	BRUNSWICK	GA	31520-4607	01/01/2019
CHC26592-01	GOLDEN ISLES PHARMACY	DONATO HEALTH, LLC	3010 ALTAMA AVE	BRUNSWICK	GA	31520-4607	01/01/2019	09/30/2021
CHC26592-00	HOLIDAY CVS, L.L.C.	CVS PHARMACY # 17237	463737 STATE RD 200	YULEE	FL	32097	09/18/2024
CHC26592-00	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 00727	5407 BLANDING BLVD.,	JACKSONVILLE	FL	32244	07/01/2025
CHC26592-00	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 00850	5999 NORMANDY BLVD	JACKSONVILLE	FL	32205	07/01/2025
CHC26592-00	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 01077	6005 ST. AUGUSTINE ROAD	JACKSONVILLE	FL	32217	07/01/2025
CHC26592-00	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 01114	4475 SAN JUAN AVENUE	JACKSONVILLE	FL	32210	07/01/2025
CHC26592-00	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03106	1625 FOURAKER ROAD	JACKSONVILLE	FL	32221	07/01/2025
CHC26592-00	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03254	1952 PARK AVE	ORANGE PARK	FL	32073	07/01/2025
CHC26592-00	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03486	906 BLANDING BLVD	ORANGE PARK	FL	32065	07/01/2025
CHC26592-00	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03685	7790 BLANDING BLVD	JACKSONVILLE	FL	32244	07/01/2025
CHC26592-00	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03923	11060 OLD ST AUGUSTINE RD	JACKSONVILLE	FL	32257	07/01/2025
CHC26592-00	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05189	1551 COUNTY RD 220	ORANGE PARK	FL	32003	07/01/2025
CHC26592-00	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05190	430 SR 13	JACKSONVILLE	FL	32259	07/01/2025
CHC26592-00	HOLIDAY CVS, L.L.C.	DBA CVS/PHARMACY # 6456	8325 BAYMEADOWS RD.	JACKSONVILLE	FL	32256	07/01/2025
CHC26592-00	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 07129	9509 SAN JOSE BLVD.	JACKSONVILLE	FL	32257	07/01/2025
CHC26592-00	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 07904	2680 RACE TRACK RD.	SAINT JOHNS	FL	32259	07/01/2025
CHC26592-00	HOLIDAY CVS, L.L.C.	CVS PHARMACY # 16643	10490 SAN JOSE BLVD	JACKSONVILLE	FL	32257	07/01/2025
CHC26592-00	HOLIDAY CVS, L.L.C.	CVSPHARMACY # 16828	1490 COUNTY RD 220	FLEMING ISLAND	FL	32003	07/01/2025
CHC26592-00	HOLIDAY CVS, L.L.C.	CVS PHARMACY # 16973	6331 ROOSEVELT BLVD	JACKSONVILLE	FL	32244	07/01/2025
CHC26592-00	HOLIDAY CVS, L.L.C.	CVS PHARMACY # 17309	9525 CROSSHILL BLVD	JACKSONVILLE	FL	32222	07/01/2025
CHC26592-02	JETS PHARMACY LLC	1229 NORTH WAY		DARIEN	GA	31305	10/01/2021	09/30/2021
CHC26592-01	JETS PHARMACY LLC	1229 NORTH WAY		DARIEN	GA	31305	10/01/2021	09/30/2021
CHC26592-00	JETS PHARMACY LLC	1229 NORTH WAY		DARIEN	GA	31305	10/01/2021
CHC26592-00	KROGER PHARMACY #688	53 EXCHANGE STREET		RICHMOND HILL	GA	31324	01/01/2024
CHC26592-00	LITTLE CREEK DRUG LLC	DBA: SOUTHERN DRUG CO-DARIEN	1001 NORTH WAY	DARIEN	GA	31305	10/01/2023
CHC26592-00	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/01/2025
CHC26592-00	PROCARE PHARMACY, L.L.C.	CVS/PHARMACY #48637	2700 NORTHEAST EXPY NE STE B800 BUILDING B	ATLANTA	GA	30345	04/01/2025
CHC26592-00	PUBLIX PHARMACY #0431	171 VILLAGE AT GLYNN PLACE	UNIT 100	BRUNSWICK	GA	31525	01/01/2019
CHC26592-00	PUBLIX PHARMACY #0455	1601 GA HIGHWAY 40 EAST		KINGSLAND	GA	31548	04/01/2023
CHC26592-00	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #3213	1950 SAND LAKE RD, BLDG #5	ORLANDO	FL	32809	01/01/2019
CHC26592-00	PUBLIX SUPER MARKETS, INC.	PUBLIX CENTRAL PHARMACY #3201	2424 ORLANDO CENTRAL PARKWAY	ORLANDO	FL	32809	01/01/2019
CHC26592-00	SAMSON MERGER SUB, LLC	WINN DIXIE #67	341 VENTURE DRIVE	BRUNSWICK	GA	31525	07/01/2019	11/30/2023
CHC26592-00	SAMSON MERGER SUB, LLC	WINN DIXIE #68	284 HYDE PARK COMMONS	BRUNSWICK	GA	31523	07/01/2019	11/30/2023
CHC26592-01	SAMSON MERGER SUB, LLC	WINN DIXIE #67	341 VENTURE DRIVE	BRUNSWICK	GA	31525	07/01/2019	09/30/2021
CHC26592-01	SAMSON MERGER SUB, LLC	WINN DIXIE #68	284 HYDE PARK COMMONS	BRUNSWICK	GA	31523	07/01/2019	09/30/2021
CHC26592-02	SAMSON MERGER SUB, LLC	WINN DIXIE #67	341 VENTURE DRIVE	BRUNSWICK	GA	31525	07/01/2019	09/30/2021
CHC26592-02	SAMSON MERGER SUB, LLC	WINN DIXIE #68	284 HYDE PARK COMMONS	BRUNSWICK	GA	31523	07/01/2019	09/30/2021
CHC26592-00	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/01/2020
CHC26592-01	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/01/2020	09/30/2021
CHC26592-02	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/01/2020	09/30/2021
CHC26592-00	WAL-MART PHARMACY 10-0639	150 ALTAMA CONNECTOR		BRUNSWICK	GA	31525	01/01/2019
CHC26592-01	WAL-MART PHARMACY 10-0639	150 ALTAMA CONNECTOR		BRUNSWICK	GA	31525	01/01/2019	09/30/2021
CHC26592-02	WAL-MART PHARMACY 10-0639	150 ALTAMA CONNECTOR		BRUNSWICK	GA	31525	01/01/2019	09/30/2021
CHC26592-00	WAL-MART PHARMACY 10-0836	6586 HWY 40 EAST		ST MARY'S	GA	31558	04/01/2023
CHC26592-00	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/01/2020
CHC26592-01	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/01/2020	09/30/2021
CHC26592-02	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/01/2020	09/30/2021
CHC26592-00	WALGREEN CO	DBA: WALGREENS #10266	101 TORRAS DRIVE	BRUNSWICK	GA	31520	01/01/2015
CHC26592-01	WALGREEN CO	DBA: WALGREENS #10266	101 TORRAS DRIVE	BRUNSWICK	GA	31520	10/01/2017	09/30/2021
CHC26592-02	WALGREEN CO	DBA: WALGREENS #10266	101 TORRAS DRIVE	BRUNSWICK	GA	31520	10/01/2017	09/30/2021
CHC26592-00	WALGREEN CO	DBA: WALGREENS #10856	2060 HIGHWAY 40 E	KINGSLAND	GA	31548-6731	04/01/2023
CHC26592-00	WALGREEN CO	DBA: WALGREENS #11538	4210 AUGUSTA RD	GARDEN CITY	GA	31408	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 07848	4575 ALTAMA AVE	BRUNSWICK	GA	31520	01/01/2015
CHC26592-00	WALGREEN CO.	DBA; WALGREENS #10506	2270 US HIGHWAY 17	RICHMOND HILL	GA	31324	10/01/2017
CHC26592-01	WALGREEN CO.	DBA: WALGREENS # 07848	4575 ALTAMA AVE	BRUNSWICK	GA	31520	10/01/2017	09/30/2021
CHC26592-02	WALGREEN CO.	DBA; WALGREENS #10506	2270 US HIGHWAY 17	RICHMOND HILL	GA	31324	07/01/2017	09/30/2021
CHC26592-02	WALGREEN CO.	DBA: WALGREENS # 07848	4575 ALTAMA AVE	BRUNSWICK	GA	31520	10/01/2017	09/30/2021
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 04449	2101 SADLER ROAD	FERNANDINA BEACH	FL	32034	10/01/2024
CHC26592-00	WALGREEN CO.	WALGREENS #18341	1038 US HIGHWAY 80 W	POOLER	GA	31322	10/01/2024
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 02171	700 EAST DERENNE AVE	SAVANNAH	GA	31405-6716	07/01/2025
CHC26592-00	WALGREEN CO.	WALGREENS #19629	4600 HABERSHAM ST	SAVANNAH	GA	31405	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS #15611	2109 E VICTORY DRIVE	SAVANNAH	GA	31404	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 05368	11509 ABERCORN ST	SAVANNAH	GA	31419	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 06098	125 JOHNNY MERCER BLVD	SAVANNAH	GA	31410	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS #10635	5701 OGEECHEE RD	SAVANNAH	GA	31405	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 06928	609 KINGSLEY AVENUE	ORANGE PARK	FL	32073	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 05297	42 BLANDING BLVD	ORANGE PARK	FL	32073	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 04081	630 BLANDING BLVD.	ORANGE PARK	FL	32073	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 09025	5990 TOWNSEND RD	JACKSONVILLE	FL	32244	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 06385	1565 COUNTY ROAD 220	ORANGE PARK	FL	32003	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 04440	1320 BLANDING BLVD.	ORANGE PARK	FL	32065	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 07350	12145 SAN JOSE BLVD	JACKSONVILLE	FL	32223	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 04736	7546 103RD STREET	JACKSONVILLE	FL	32210	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 07979	9700 ARGYLE FOREST BLVD	JACKSONVILLE	FL	32222	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 07667	390 STATE ROAD 13 N	JACKSONVILLE	FL	32259	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 03382	3604 BLANDING BLVD	JACKSONVILLE	FL	32210	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 04325	4297 OLDFIELD CROSSING DR.	JACKSONVILLE	FL	32223	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 04278	8917 SAN JOSE BLVD.	JACKSONVILLE	FL	32257	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 09026	105 JULINGTON PLAZA DR	JACKSONVILLE	FL	32259-6218	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 03755	3505 UNIVERSITY BLVD. WEST	JACKSONVILLE	FL	32217	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS #13450	8018 NORMANDY BLVD	JACKSONVILLE	FL	32221	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 02220	7221 NORMANDY BLVD	JACKSONVILLE	FL	32205-6260	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 03746	2703 PARK ST.	JACKSONVILLE	FL	32205	07/01/2025
CHC26592-00	WALGREEN CO.	DBA: WALGREENS # 04638	654 CASSAT AVE	JACKSONVILLE	FL	32205	07/01/2025
CHC26592-00	WALGREENS MAIL SERVICE, INC.		8337 S PARK CIRCLE	ORLANDO	FL	32819-9049	01/01/2015	06/24/2015
CHC26592-00	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	01/01/2015	06/24/2015
CHC26592-00	WALMART PHARMACY #10-2840	11 GLYNN PLAZA		BRUNSWICK	GA	31520	01/01/2019
CHC26592-01	WALMART PHARMACY #10-2840	11 GLYNN PLAZA		BRUNSWICK	GA	31520	01/01/2019	09/30/2021
CHC26592-02	WALMART PHARMACY #10-2840	11 GLYNN PLAZA		BRUNSWICK	GA	31520	01/01/2019	09/30/2021
CHC26592-00	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/01/2023
CHC26592-00	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024
CHC26592-00	WINN DIXIE PHARMACY # 19	220 RETREAT VILLAGE		SAINT SIMONS ISLAND	GA	31522	07/01/2019	11/30/2023
CHC26592-01	WINN DIXIE PHARMACY # 19	220 RETREAT VILLAGE		SAINT SIMONS ISLAND	GA	31522	07/01/2019	09/30/2021
CHC26592-02	WINN DIXIE PHARMACY # 19	220 RETREAT VILLAGE		SAINT SIMONS ISLAND	GA	31522	07/01/2019	09/30/2021
CHC26592-00	WOODBINE MEDICAL, LLC	DBA WOODBINE PHARMACY	908 GEORGIA AVE # 1	WOODBINE	GA	31569-3574	10/01/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2023 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		6/20/2022 12:00:00 AM	12/9/2022 2:05 PM
Details	State	Update	Termination Request	Active	To Be Terminated	12/9/2022 2:05 PM
Terminations	Termination Date	Update	Termination Request		1/1/2023 12:00:00 AM	12/9/2022 2:05 PM
Terminations	Termination Effective Date	Update	Termination Request		7/21/2022 12:00:00 AM	12/9/2022 2:05 PM
Terminations	Termination Reason	Update	Termination Request		Site closure	12/9/2022 2:05 PM
Details	Last Recertification Date	Update	Recertification	2/1/2021 4:58:03 PM	1/31/2022 3:59:05 PM	1/31/2022 3:59 PM
Contacts	Authorizing Official	Update	Group Change Request	Meyers, Barbara CEO Coastal Community Health Services 9125745074	Chandler, Kavanaugh CEO Coastal Community Health Services 9122758028-1139	9/16/2021 8:03 AM
Details	Last Recertification Date	Update	Recertification	1/29/2020 1:54:49 PM	2/1/2021 4:58:03 PM	2/1/2021 4:58 PM
Details	Last Recertification Date	Update	Recertification	1/29/2019 10:54:22 AM	1/29/2020 1:54:49 PM	1/29/2020 1:54 PM
Details	Last Recertification Date	Update	Recertification	2/8/2018 9:57:34 AM	1/29/2019 10:54:22 AM	1/29/2019 10:54 AM
Contacts	Primary Contact	Update	Profile Change Request	Senol, Martina CFO Coastal Community Health Services, Inc. 9122892900	Senol, Martina CFO Coastal Community Health Services, Inc. 9122758028-111	1/29/2019 9:38 AM
Contacts	Primary Contact	Update	Recertification	Meyers, Barbara CEO Coastal Community Health Services 9125745074	Senol, Martina CFO Coastal Community Health Services, Inc. 9122892900	2/8/2018 9:57 AM
Details	Last Recertification Date	Update	Recertification		2/8/2018 9:57:34 AM	2/8/2018 9:57 AM
Details	Is Authorizing Official EHB Data	Update	Recertification	False		2/8/2018 9:57 AM
Contacts	Authorizing Official	Update	Profile Change Request	Meyers, Barbara CEO Coastal Community Health Services 9122758028	Meyers, Barbara CEO Coastal Community Health Services 9125745074	1/8/2018 11:48 AM
Contacts	Primary Contact	Update	Profile Change Request	Meyers, Barbara CEO Coastal Community Health Services 9122758028	Meyers, Barbara CEO Coastal Community Health Services 9125745074	1/8/2018 11:48 AM
Contacts	Signed By	Update	Profile Change Request	Meyers, Barbara CEO Coastal Community Health Services 9122758028	Meyers, Barbara CEO Coastal Community Health Services 9125745074	1/8/2018 11:48 AM
Contacts	Authorizing Official	Update		Meyers, Barbara CEO 9122758028	Meyers, Barbara CEO Coastal Community Health Services 9122758028	9/25/2017 5:13 PM
Contacts	Primary Contact	Update		Meyers, Barbara CEO 9122758028	Meyers, Barbara CEO Coastal Community Health Services 9122758028	9/25/2017 5:13 PM
Contacts	Signed By	Update		Meyers, Barbara CEO 9122758028	Meyers, Barbara CEO Coastal Community Health Services 9122758028	9/25/2017 5:13 PM
Contacts	Authorizing Official	Insert			Meyers, Barbara CEO 9122758028	7/17/2017 5:47 PM
Contacts	Primary Contact	Insert			Meyers, Barbara CEO 9122758028	7/17/2017 5:47 PM
Contacts	Signed By	Insert			Meyers, Barbara CEO 9122758028	7/17/2017 5:47 PM
Addresses	Main Address	Insert			2211 Bartow Street Brunswick, GA 31520-5604	5/16/2017 10:11 AM
Addresses	Billing Address	Insert			Coastal Community Health Services, INC. 106 Shoppers Way Suite 1 Brunswick, GA 31525	4/24/2017 10:25 AM
Dates	Participating Approval Date	Update			4/24/2017 12:00:00 AM	4/24/2017 10:25 AM
Details	State	Update		Pending	Active	4/24/2017 10:25 AM
Dates	Start Date	Update			7/1/2017 12:00:00 AM	4/24/2017 10:25 AM
Details	340B ID	Update		ONLINE_REG_76971	CHC26592-01	4/18/2017 12:11 PM
Details	340B ID	Update		ONLINE_REG	ONLINE_REG_76971	4/14/2017 10:56 AM
Details	Last Recertification Date	Insert				4/14/2017 10:56 AM
Details	Grant Number	Insert			H80CS26592	4/14/2017 10:56 AM
Details	340B ID	Insert			ONLINE_REG	4/14/2017 10:56 AM
Details	Is Authorizing Official EHB Data	Insert			False	4/14/2017 10:56 AM
Dates	Last Date That 340B Drugs Purchased	Insert				4/14/2017 10:56 AM
Details	Medicare Provider Number	Insert				4/14/2017 10:56 AM
Details	Entity Name	Insert			COASTAL COMMUNITY HEALTH SERVICES, INC.	4/14/2017 10:56 AM
Details	Program Code	Insert			CH	4/14/2017 10:56 AM
Details	Entity Subname	Insert			Perry Park	4/14/2017 10:56 AM
Dates	Participating Approval Date	Insert				4/14/2017 10:56 AM
Details	State	Insert			Pending	4/14/2017 10:56 AM
Dates	Registration Date	Insert			4/14/2017 12:00:00 AM	4/14/2017 10:56 AM
Dates	Signed By Date	Insert			4/14/2017 12:00:00 AM	4/14/2017 10:56 AM
Dates	Start Date	Insert				4/14/2017 10:56 AM
Terminations	Termination Comments	Insert				4/14/2017 10:56 AM
Terminations	Termination Date	Insert				4/14/2017 10:56 AM
Terminations	Termination Effective Date	Insert				4/14/2017 10:56 AM
Terminations	Termination Reason	Insert				4/14/2017 10:56 AM

340B Drug Pricing Program Database