Covered Entity Details

URB12040 NATIVE AMERICAN HEALTH CENTER (Active) - information as of 5/25/2025 1:13:34 AM

Main Details

Name

NATIVE AMERICAN HEALTH CENTER

Subdivision Name

DBA NATIVE AMERICAN HEALTH CENTER

Type

Urban Indian

340B ID

URB12040

Additional Details

Current Program Status

Active

Registration Date

12/1/1992

Participating Start Date

12/1/1992

Participating Approval Date

1/5/2004

Last Recertification Date

2/11/2025

Contacts

Authorizing Official

Native American Health Center
Elvia Guevara, Director of Medical Operations
(510) 535-4472

Primary Contact

Native American Health Center
Luis Sanchez, Executive Assistant
(510) 535-4472

Addresses

Street Address

3124 INTERNATIONAL BLVD.
OAKLAND, CA 94601

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
History

Comments

Comment	Last Updated On
ADDED E-MAIL ADDRESS updated clinic name and authorizing official JH	11/02/2011
ADDED E-MAIL ADDRESS	01/05/2004

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
CA	1689863516	1689863516

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	DOLPHIN HEALTH PHARMACY	7400 MACARTHUR BLVD	SUITE A	OAKLAND	CA	94605	01/12/2018	04/01/2018		01/12/2018
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17623	789 MISSION ST	SAN FRANCISCO	CA	94103	01/14/2022	04/01/2022		04/01/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10368	400 SUTTER ST.	SAN FRANCISCO	CA	94108	01/14/2022	04/01/2022	01/01/2022	08/09/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY #11107	701 VAN NESS AVENUE	SAN FRANCISCO	CA	94102	01/14/2022	04/01/2022		04/01/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY # 4675	377 32ND AVENUE	SAN FRANCISCO	CA	94121	01/14/2022	04/01/2022		04/01/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY # 2852	731 MARKET ST.	SAN FRANCISCO	CA	94103	01/14/2022	04/01/2022		04/01/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY #10495	399 GEARY STREET	SAN FRANCISCO	CA	94102	01/14/2022	04/01/2022	01/01/2022	08/09/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY # 10492	500 PINE ST	SAN FRANCISCO	CA	94108	01/14/2022	04/01/2022	01/01/2022	08/09/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #5131	1900 19TH AVENUE	SAN FRANCISCO	CA	94116	01/14/2022	04/01/2022		04/01/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10330	3600 GEARY BLVD	SAN FRANCISCO	CA	94118	01/14/2022	04/01/2022		04/01/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10475	2964 BROADWAY	OAKLAND	CA	94611	01/14/2022	04/01/2022	01/03/2023	08/09/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17657	2700 5TH ST	ALAMEDA	CA	94501	01/14/2022	04/01/2022		04/01/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY# 1983	701 PORTOLA DR	SAN FRANCISCO	CA	94127	01/14/2022	04/01/2022		04/01/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY # 17709	233 WINSTON DRIVE	SAN FRANCISCO	CA	94132	01/14/2022	04/01/2022		04/01/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17624	1555 40TH STREET	EMERYVILLE	CA	94608	01/14/2022	04/01/2022		04/01/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16764	15555 E 14TH ST STE 400	SAN LEANDRO	CA	94578	01/14/2022	04/01/2022		04/01/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17672	225 BUSH ST. #100	SAN FRANCISCO	CA	94104	01/14/2022	04/01/2022	10/01/2021	08/09/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY # 10080	1059 HYDE ST.	SAN FRANCISCO	CA	94109	01/14/2022	04/01/2022		04/01/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10164	601 MISSION STREET	SAN FRANCISCO	CA	94105	01/14/2022	04/01/2022		04/01/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY # 7657	351 CALIFORNIA STREET	SAN FRANCISCO	CA	94104	01/14/2022	04/01/2022	01/01/2022	08/09/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY # 11004	799 BEACH STREET	SAN FRANCISCO	CA	94109	01/14/2022	04/01/2022	01/01/2022	08/09/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10188	499 HAIGHT STREET	SAN FRANCISCO	CA	94117	01/14/2022	04/01/2022		04/01/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17265	19661 HESPERIAN BLVD	HAYWARD	CA	94541	01/14/2022	04/01/2022		04/01/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY # 10035	581 MARKET ST	SAN FRANCISCO	CA	94105	01/14/2022	04/01/2022	01/01/2022	08/09/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY # 8431	7200 BANCROFT AVE.	OAKLAND	CA	94605	01/14/2022	04/01/2022		04/01/2022
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17625	2675 GEARY BLVD	SAN FRANCISCO	CA	94118	01/14/2022	04/01/2022		04/01/2022
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09876	699 LEWELLING BLVD	SAN LEANDRO	CA	94579	01/14/2022	04/01/2022		04/01/2022
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09250	885 ISLAND DR STE A	ALAMEDA	CA	94502	01/14/2022	04/01/2022		04/01/2022
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09255	931 MARINA VILLAGE PKWY	ALAMEDA	CA	94501	01/14/2022	04/01/2022		04/01/2022
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09378	4100 REDWOOD RD	OAKLAND	CA	94619	01/14/2022	04/01/2022		04/01/2022
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09635	1550 EAST 14TH STREET	SAN LEANDRO	CA	94577	01/14/2022	04/01/2022		04/01/2022
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09203	580 MORAGA RD	MORAGA	CA	94556	01/14/2022	04/01/2022		04/01/2022
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09226	3320 FRUITVALE AVE	OAKLAND	CA	94602	01/14/2022	04/01/2022		04/01/2022
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09929	2000 MOUNTAIN BLVD	OAKLAND	CA	94611	01/14/2022	04/01/2022		04/01/2022
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09128	2314 SANTA CLARA AVE	ALAMEDA	CA	94501	01/14/2022	04/01/2022		04/01/2022
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09957	344 THOMAS L. BERKLEY WAY	OAKLAND	CA	94612	01/14/2022	04/01/2022	07/20/2022	08/09/2023
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09372	1480 MORAGA RD STE D	MORAGA	CA	94556	01/14/2022	04/01/2022		04/01/2022
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09942	1401 WASHINGTON AVE	SAN LEANDRO	CA	94577	01/14/2022	04/01/2022		04/01/2022
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09130	175 41ST ST	OAKLAND	CA	94611	01/14/2022	04/01/2022		04/01/2022
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 07955	2025 VAN NESS AVE	SAN FRANCISCO	CA	94109	01/14/2022	04/01/2022	07/20/2022	08/09/2023
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09904	3667 CASTRO VALLEY BLVD	CASTRO VALLEY	CA	94546	01/14/2022	04/01/2022		04/01/2022
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09553	4349 SAN PABLO AVE	EMERYVILLE	CA	94608	01/14/2022	04/01/2022	08/30/2022	08/09/2023
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 00816	22501 FOOTHILL BLVD	HAYWARD	CA	94541	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO	DBA: WALGREENS #11385	1580 VALENCIA ST STE 101	SAN FRANCISCO	CA	94110	07/19/2013	10/01/2013	04/21/2022	08/09/2023
Contract Detail	WALGREEN CO	DBA: WALGREENS #10526	3250 LAKESHORE AVE STE B	OAKLAND	CA	94610-2720	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01126	1979 MISSION STREET	SAN FRANCISCO	CA	94103	07/19/2013	10/01/2013	12/26/2019	01/20/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01327	498 CASTRO ST	SAN FRANCISCO	CA	94114	07/19/2013	10/01/2013		03/07/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01536	3434 HIGH STREET	OAKLAND	CA	94619	07/19/2013	10/01/2013		03/07/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01537	3232 FOOTHILL BLVD	OAKLAND	CA	94601	07/19/2013	10/01/2013		03/07/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02153	790 VAN NESS AVE	SAN FRANCISCO	CA	94102	07/19/2013	10/01/2013	11/11/2020	01/20/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02426	15500 WASHINGTON AVE	SAN LEANDRO	CA	94579	07/19/2013	10/01/2013		03/07/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02866	1363 DIVISADERO ST	SAN FRANCISCO	CA	94115	07/19/2013	10/01/2013		03/07/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03032	15850 E 14TH STREET	SAN LEANDRO	CA	94578	07/19/2013	10/01/2013	02/21/2017	09/23/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03170	3400 TELEGRAPH AVENUE	OAKLAND	CA	94609	07/19/2013	10/01/2013	11/08/2022	08/09/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03295	8102 INTERNATIONAL BLVD	OAKLAND	CA	94621	07/19/2013	10/01/2013	07/09/2021	08/09/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03711	1189 POTRERO AVE	SAN FRANCISCO	CA	94110	07/19/2013	10/01/2013		03/07/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04231	2690 MISSION ST	SAN FRANCISCO	CA	94110	07/19/2013	10/01/2013		03/07/2017
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #04318	4129 18TH STREET	SAN FRANCISCO	CA	94114	07/19/2013	10/01/2013		03/07/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04529	2145 MARKET STREET	SAN FRANCISCO	CA	94114	07/19/2013	10/01/2013		03/07/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04609	1301 MARKET STREET	SAN FRANCISCO	CA	94103	07/19/2013	10/01/2013		03/07/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05487	5300 3RD STREET	SAN FRANCISCO	CA	94124	07/19/2013	10/01/2013		03/07/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09248	2300 OTIS DRIVE	ALAMEDA	CA	94501	07/19/2013	10/01/2013		03/07/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11706	301 E. 18TH STREET	OAKLAND	CA	94606-1813	07/19/2013	10/01/2013		03/07/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #13668	1496 MARKET STREET	SAN FRANCISCO	CA	94102	07/19/2013	10/01/2013	08/31/2020	01/20/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 13595	1333 BROADWAY STE 145	OAKLAND	CA	94612	03/16/2015	04/01/2015		03/07/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04050	1916 WEBSTER ST.	ALAMEDA	CA	94501	03/16/2015	04/01/2015		03/07/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #13583	901 HYDE STREET	SAN FRANCISCO	CA	94109	01/13/2017	04/01/2017	08/01/2019	09/19/2019
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16477	3009 BROADWAY	OAKLAND	CA	94611	01/13/2017	04/01/2017		03/07/2017
Contract Detail	WALGREEN CO.	WALGREENS #15330	5809 FOOTHILL BLVD	OAKLAND	CA	94605	01/15/2020	04/01/2020		04/01/2020
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #15296	2262 MARKET ST	SAN FRANCISCO	CA	94114	01/15/2020	04/01/2020		04/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03185	825 MARKET STREET	SAN FRANCISCO	CA	94103	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #00890	135 POWELL STREET	SAN FRANCISCO	CA	94102	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01054	3398 MISSION ST	SAN FRANCISCO	CA	94110	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 15025	2190 SHATTUCK AVENUE	BERKELEY	CA	94704-1307	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02150	1763 SANTA RITA RD	PLEASANTON	CA	94566	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01625	5055 TELEGRAPH AVE	OAKLAND	CA	94609	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05365	6100 MISSION STREET	DALY CITY	CA	94014	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07274	1456 136TH AVE	SAN LEANDRO	CA	94578-2552	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04275	456 MISSION STREET	SAN FRANCISCO	CA	94105	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03346	399 EL CAMINO REAL	SOUTH SAN FRANCISCO	CA	94080	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04659	164 W. JACKSON ST.	HAYWARD	CA	94544	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04026	2900 N MAIN ST	WALNUT CREEK	CA	94597	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02314	1050 GILMAN ST	BERKELEY	CA	94710	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03358	1301 FRANKLIN ST	SAN FRANCISCO	CA	94109	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 00893	1344 STOCKTON ST	SAN FRANCISCO	CA	94133	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02401	21463 FOOTHILL BLVD.	HAYWARD	CA	94541	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15331	500 PARNASSUS AVENUE LEVEL J, ROOM MU-145	SAN FRANCISCO	CA	94143	01/14/2022	04/01/2022	12/14/2023	04/04/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 00101	3382 CASTRO VALLEY BLVD	CASTRO VALLEY	CA	94546	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04614	2801 ADELINE ST	BERKELEY	CA	94703	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02306	1138 W TENNYSON RD	HAYWARD	CA	94544	01/14/2022	04/01/2022		04/01/2022
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	07/19/2013	10/01/2013	07/21/2015	03/07/2017

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	2/8/2024 7:25:42 PM	2/11/2025 2:30:44 PM	2/11/2025 2:30 PM
Contacts	Authorizing Official	Update	Change Request	Garrett, Greg C Chief Operating Officer Native American Health Center 5104855902	Guevara, Elvia Director of Medical Operations Native American Health Center 5105354472	1/23/2025 12:51 PM
Contacts	Primary Contact	Update	Change Request	Guevara, Elvia Director of Medical Operations Native American Health Center 5105354472	Sanchez, Luis Executive Assistant Native American Health Center 5105354472	1/23/2025 12:51 PM
Details	Last Recertification Date	Update	Recertification	2/23/2023 2:28:52 PM	2/8/2024 7:25:42 PM	2/8/2024 7:25 PM
Contacts	Primary Contact	Update	Change Request	Guevara, Elvia Director of Medical Operations Native American Health Center 5104854472	Guevara, Elvia Director of Medical Operations Native American Health Center 5105354472	8/16/2023 5:07 PM
Contacts	Primary Contact	Update	Change Request	Harrison, Charlene Site Director Native American Health Center 5105354472	Guevara, Elvia Director of Medical Operations Native American Health Center 5104854472	8/14/2023 7:09 AM
Details	Last Recertification Date	Update	Recertification	2/11/2022 6:00:58 PM	2/23/2023 2:28:52 PM	2/23/2023 2:28 PM
Details	Last Recertification Date	Update	Recertification	2/25/2021 4:27:24 PM	2/11/2022 6:00:58 PM	2/11/2022 6:00 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	2/25/2021 4:27 PM
Details	Last Recertification Date	Update	Recertification	2/6/2020 4:01:47 PM	2/25/2021 4:27:24 PM	2/25/2021 4:27 PM
Details	Last Recertification Date	Update	Recertification	2/4/2019 11:11:33 AM	2/6/2020 4:01:47 PM	2/6/2020 4:01 PM
Contacts	Authorizing Official	Update	AO Change Request	O'Connor, Ana Chief Operating Officer Native American Health Center 5104345470	Garrett, Greg C Chief Operating Officer Native American Health Center 5104855902	1/31/2020 8:10 AM
Details	Last Recertification Date	Update	Recertification	2/20/2018 2:24:19 PM	2/4/2019 11:11:33 AM	2/4/2019 11:11 AM
Details	Last Recertification Date	Update	Recertification	2/23/2017 12:00:00 AM	2/20/2018 2:24:19 PM	2/20/2018 2:24 PM
Contacts	Primary Contact	Update	Recertification	Harrison, Charlene Site Director 5105354472	Harrison, Charlene Site Director Native American Health Center 5105354472	2/20/2018 2:04 PM
Contacts	Authorizing Official	Update		O'Connor, Ana Chief Operating Officer 5104345470	O'Connor, Ana Chief Operating Officer Native American Health Center 5104345470	1/5/2018 12:54 PM
Contacts	Authorizing Official	Update		Jamerson, Susan Director 5105354472	O'Connor, Ana Chief Operating Officer 5104345470	3/9/2017 1:38 PM
Contacts	Primary Contact	Update		WAUKAZOO, MARTIN CEO 5105354460	Harrison, Charlene Site Director 5105354472	3/9/2017 1:38 PM
Addresses	Main Address	Insert			3124 INTERNATIONAL BLVD. OAKLAND, CA 94601	3/9/2017 1:33 PM
Dates	Last Date That 340B Drugs Purchased	Update		4/1/2017 12:00:00 AM		3/7/2017 12:38 PM
Details	State	Update		Terminated	Active	3/7/2017 12:38 PM
Terminations	Termination Date	Update		4/1/2017 12:00:00 AM		3/7/2017 12:38 PM
Terminations	Termination Effective Date	Update		4/1/2017 12:00:00 AM		3/7/2017 12:38 PM
Terminations	Termination Reason	Update		Failure to recertify		3/7/2017 12:38 PM
Details	Last Recertification Date	Update		3/9/2016 12:00:00 AM	2/23/2017 12:00:00 AM	2/23/2017 10:35 AM
Dates	Last Date That 340B Drugs Purchased	Update			4/1/2017 12:00:00 AM	2/23/2017 10:35 AM
Details	State	Update		Active	Terminated	2/23/2017 10:35 AM
Terminations	Termination Date	Update			4/1/2017 12:00:00 AM	2/23/2017 10:35 AM
Terminations	Termination Effective Date	Update			4/1/2017 12:00:00 AM	2/23/2017 10:35 AM
Terminations	Termination Reason	Update			Failure to recertify	2/23/2017 10:35 AM
Details	Last Recertification Date	Update		3/3/2015 12:00:00 AM	3/9/2016 12:00:00 AM	3/9/2016 6:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/3/2015 7:46 AM
Medicaid Billing	Medicaid: Number	Insert			1689863516	3/3/2015 7:46 AM
Medicaid Billing	Medicaid: State	Insert			CA	3/3/2015 7:46 AM
Medicaid Billing	NPI: Number	Insert			1689863516	3/3/2015 7:46 AM
Details	Last Recertification Date	Update		3/14/2014 12:00:00 AM	3/3/2015 12:00:00 AM	3/3/2015 7:46 AM
Details	Last Recertification Date	Update		4/1/2013 12:00:00 AM	3/14/2014 12:00:00 AM	3/14/2014 2:41 PM
Details	Last Recertification Date	Update			4/1/2013 12:00:00 AM	2/21/2013 7:23 AM
Contacts	Primary Contact	Insert			WAUKAZOO, MARTIN CEO 5105354460	11/7/2011 9:12 AM
Contacts	Authorizing Official	Insert			Jamerson, Susan Director 5105354472	11/7/2011 9:12 AM
Details	Entity Name	Update		URBAN INDIAN HEALTH BOARD	NATIVE AMERICAN HEALTH CENTER	11/2/2011 2:20 PM
Dates	Participating Approval Date	Update		1/5/2004 2:21:45 PM	1/5/2004 12:00:00 AM	11/2/2011 2:20 PM
Details	Comments Public	Insert			ADDED E-MAIL ADDRESS updated clinic name and authorizing official JH	11/2/2011 2:20 PM
Details	Last Recertification Date	Insert				1/5/2004 2:21 PM
Details	Grant Number	Insert				1/5/2004 2:21 PM
Details	340B ID	Insert			URB12040	1/5/2004 2:21 PM
Details	Is Authorizing Official EHB Data	Insert				1/5/2004 2:21 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/5/2004 2:21 PM
Details	Medicare Provider Number	Insert				1/5/2004 2:21 PM
Details	Entity Name	Insert			URBAN INDIAN HEALTH BOARD	1/5/2004 2:21 PM
Details	Program Code	Insert			UI	1/5/2004 2:21 PM
Details	Entity Subname	Insert			DBA NATIVE AMERICAN HEALTH CENTER	1/5/2004 2:21 PM
Dates	Participating Approval Date	Insert			1/5/2004 2:21:45 PM	1/5/2004 2:21 PM
Details	State	Insert			Active	1/5/2004 2:21 PM
Dates	Registration Date	Insert			12/1/1992 12:00:00 AM	1/5/2004 2:21 PM
Dates	Signed By Date	Insert				1/5/2004 2:21 PM
Dates	Start Date	Insert			12/1/1992 12:00:00 AM	1/5/2004 2:21 PM
Terminations	Termination Comments	Insert				1/5/2004 2:21 PM
Terminations	Termination Date	Insert				1/5/2004 2:21 PM
Terminations	Termination Effective Date	Insert				1/5/2004 2:21 PM
Terminations	Termination Reason	Insert				1/5/2004 2:21 PM
Details	Comments Public	Insert			ADDED E-MAIL ADDRESS	1/5/2004 2:21 PM

340B Drug Pricing Program Database

Comments

Medicaid Billing

Shipping Addresses

Contract Pharmacies

History