Covered Entity Details

CH09544AC La Maestra Family Clinic, Inc. (Active) - information as of 4/30/2025 10:55:12 PM

Main Details

Name

La Maestra Family Clinic, Inc.

Subdivision Name

La Maestra Hoover High School Medical and Dental Clinic

Type

HRSA-Funded Health Center

Site ID

BPS-H80-010376

340B ID

CH09544AC

Grant Number

H80CS00812

Additional Details

Current Program Status

Active

Registration Date

12/12/2017

Participating Start Date

1/1/2018

Participating Approval Date

12/12/2017

Last Recertification Date

2/12/2025

Contacts

Authorizing Official

La Maestra Family Clinic, Inc.
ZARA MARSELIAN, CEO
(619) 584-1612 Ext: 3018

Primary Contact

La Maestra Family Clinic, Inc.
Tom Vu, Executive Director
(619) 972-4165

Addresses

Street Address

4474 El Cajon Blvd
San Diego, CA 92115-4312

Billing Address

La Maestra Family Clinic, Inc.
4060 Fairmount Ave
San Diego, CA 92105

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
CA	FHC70472G	1609849074

Shipping Addresses

Shipping Address 1

La Maestra Family Clinic, Inc.
4060 Fairmount Ave
San Diego, CA 92105

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
CH095440	Active	BPS-H80-008640	La Maestra Family Clinic, Inc.	La Maestra Family clinic	4060 Fairmount Ave	San Diego	CA
CH09544AA	Terminated	BPS-H80-019344	La Maestra Family Clinic, Inc.	La Maestra Lemon Grove Dental Clinic	7139 Broadway	Lemon Grove	CA
CH09544AB	Active	BPS-H80-010260	La Maestra Family Clinic, Inc.	La Maestra Central Elementary School Clinic	4063 Polk Ave	San Diego	CA
CH09544AC	Active	BPS-H80-010376	La Maestra Family Clinic, Inc.	La Maestra Hoover High School Medical and Dental Clinic	4474 El Cajon Blvd	San Diego	CA
CH09544AD	Active	BPS-H80-010956	La Maestra Family Clinic, Inc.	La Maestra Monroe Clark Middle School Clinic	4388 Thorn St	San Diego	CA
CH09544AE	Terminated	BPS-H80-010991	La Maestra Family Clinic, Inc.	La Maestra Rosa Parks Elementary Clinic	4510 Landis St	San Diego	CA
CH09544AF	Active	BPS-H80-013175	La Maestra Family Clinic, Inc.	La Maestra Hope Clinic	4171 Fairmount Ave	San Diego	CA
CH09544AG	Active	BPS-H80-030578	LA MAESTRA FAMILY CLINIC, INC.	La Maestra City Heights Clinic	4074 Fairmount Ave	San Diego	CA
CH09544AH	Active	BPS-H80-037626	LA MAESTRA FAMILY CLINIC, INC.	La Maestra Rea Avenue Clinic	181 Rea Ave	El Cajon	CA
CH09544B	Active	BPS-H80-004366	La Maestra Family Clinic, Inc.	EL CAJON DENTAL CLINIC	183 S 1st St	El Cajon	CA
CH09544C	Active	BPS-H80-000691	La Maestra Family Clinic, Inc.	EL CAJON MEDICAL CLINIC	165 S 1st St	El Cajon	CA
CH09544W	Active	BPS-H80-010957	La Maestra Family Clinic, Inc.	National City Highland clinic	217 Highland Ave	San Diego	CA
CH09544X	Active	BPS-H80-004899	La Maestra Family Clinic, Inc.	LA MAESTRA CLINIC DENTAL SITE	4305 UNIVERSITY AVE STE 150	SAN DIEGO	CA
CH09544Y	Active	BPS-H80-009996	La Maestra Family Clinic, Inc.	LA MAESTRA LEMON GROVE CLINIC	7967 Broadway	Lemon Grove	CA
CH09544Z	Active	BPS-H80-017457	LA MAESTRA FAMILY CLINIC, INC.	La Maestra El Cajon Primary Care Clinic	1032 Broadway	El Cajon	CA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH095440	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	07/01/2019
CH095440	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	07/01/2019
CH095440	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	07/01/2019
CH095440	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	07/01/2019
CH095440	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	07/01/2019
CH095440	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	07/01/2019
CH095440	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	04/01/2017
CH095440	AVELLA OF DEER VALLEY, INC. #38	DBA AVELLA SPECIALTY PHARMACY	24416 N. 19TH AVE	PHOENIX	AZ	85085	04/01/2017	06/21/2021
CH095440	AVELLA OF SACRAMENTO, INC.	2288 AUBURN BLVD #102		SACRAMENTO	CA	95821	07/01/2017
CH095440	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	01/01/2025
CH095440	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	01/01/2025
CH095440	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	01/01/2025
CH095440	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	01/01/2025
CH095440	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	01/01/2025
CH095440	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	01/01/2025
CH095440	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	01/01/2025
CH095440	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	01/01/2025
CH095440	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/01/2017
CH095440	COMMUNITY MEDICAL CENTER PHARMACY	610 GATEWAY CENTER WAY	STE A - E	SAN DIEGO	CA	92102-4548	01/01/2018	07/18/2018
CH095440	GALLOWAY'S MEDICAL CENTER PHARMACY	2995 NATIONAL AVENUE		SAN DIEGO	CA	92113	01/01/2018	07/18/2018
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09193	1380 43RD ST.	SAN DIEGO	CA	92113	01/01/2020
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09138	1201 E. PLAZA BLVD	NATIONAL CITY	CA	91950	01/01/2020
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09177	8260 MIRA MESA BLVD.	SAN DIEGO	CA	92126	01/01/2020
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09115	645 SATURN BLVD	SAN DIEGO	CA	92154	01/01/2020
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09148	313 WASHINGTON ST.	SAN DIEGO	CA	92103	01/01/2020
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08842	426 EAST CHASE AVENUE	EL CAJON	CA	92020	01/01/2020
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09145	9730 MISSION GORGE RD.	SANTEE	CA	92071	01/01/2020
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09112	7100 BROADWAY	LEMON GROVE	CA	91945	01/01/2020
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09109	6265 EL CAJON BLVD	SAN DIEGO	CA	92115	01/01/2020
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09114	1299 BROADWAY	EL CAJON	CA	92021	01/01/2020
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09141	3151 UNIVERSITY AVE.	SAN DIEGO	CA	92104	01/01/2020
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09121	4404 EL CAJON BLVD	SAN DIEGO	CA	92115	01/01/2020
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08859	16 3RD AVENUE EXT.	CHULA VISTA	CA	91910	01/01/2020
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09173	2760 FLETCHER PKY	EL CAJON	CA	92020	04/01/2020
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 04768	510 C STREET	SAN DIEGO	CA	92101	07/01/2021
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09195	8831 VILLA LA JOLLA DR.	LA JOLLA	CA	92037	07/01/2021
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09585	3925 N. RIVER RD.	OCEANSIDE	CA	92058	07/01/2021
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09524	3350 PALM AVE.	SAN DIEGO	CA	92154	07/01/2021
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09137	7393 JACKSON DR.	SAN DIEGO	CA	92119	07/01/2021
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09197	9225 TWIN TRAILS DRIVE	SAN DIEGO	CA	92129	10/01/2021
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09140	555 BROADWAY STE 1054	CHULA VISTA	CA	91910	10/01/2021
CH095440	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16102	250 BROADWAY	EL CAJON	CA	92021	10/01/2021
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10819	1850 5TH AVENUE	SAN DIEGO	CA	92101	10/01/2021
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10919	9665 CAMPO RD.	SPRING VALLEY	CA	91977	10/01/2021
CH095440	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09105	12358 POWAY ROAD	POWAY	CA	92064	10/01/2021
CH095440	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09167	790 JAMACHA RD	EL CAJON	CA	92019	01/01/2020
CH095440	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09818	572 FLETCHER PKWY	EL CAJON	CA	92020	01/01/2020
CH095440	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 06332	645 MARKET ST	SAN DIEGO	CA	92101	01/01/2020
CH095440	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09963	5644 MISSION CENTER RD SUITE 201	SAN DIEGO	CA	92108	07/01/2021
CH095440	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 07962	5685 BALBOA AVE	SAN DIEGO	CA	92111	07/01/2021
CH095440	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09632	691 3RD AVE	CHULA VISTA	CA	91910	07/01/2021
CH095440	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09783	1730 SWEETWATER RD	NATIONAL CITY	CA	91950	10/01/2021
CH095440	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 03914	11655 DUENDA RD	SAN DIEGO	CA	92127	10/01/2021
CH095440	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 03068	10776 WESTVIEW PKWY	SAN DIEGO	CA	92126	10/01/2021
CH095440	MEDICAL CENTER PHARMACY	4074 FAIRMONT AVENUE		SAN DIEGO	CA	92105	01/01/2018	07/18/2018
CH095440	MEDICAL CENTER PHARMACY	3904 PARK BLVD		SAN DIEGO	CA	92103	01/01/2018	07/18/2018
CH095440	MEDICAL CENTER PHARMACY	PARK MEDICAL PHARMACY	480 4TH AVE STE 100	CHULA VISTA	CA	91910	01/01/2018	07/18/2018
CH095440	MEDICAL CENTER PHARMACY	340 4TH AVENUE	SUITE 1	CHULA VISTA	CA	91910	01/01/2018	07/18/2018
CH095440	MEDICAL CENTER PHARMACY	MCP16	286 EUCLID AVE, #206	SAN DIEGO	CA	92114	01/01/2018	07/18/2018
CH095440	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	06/18/2021
CH095440	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	01/01/2025
CH095440	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY	1010 UNIVERSITY AVENUE	SAN DIEGO	CA	92103	07/01/2020
CH095440	TENNESSEE CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07794	106 INDEPENDENCE LN	LA FOLLETTE	TN	37766	07/01/2021
CH095440	THRIFTY PAYLESS, INC.	RITE AID #5625	1135 AVOCADO BOULEVARD	EL CAJON	CA	92020	01/01/2018	01/30/2023
CH095440	THRIFTY PAYLESS, INC.	RITE AID #5618	7224 BROADWAY	LEMON GROVE	CA	91945	01/01/2018
CH095440	THRIFTY PAYLESS, INC.	RITE AID #5620	661 SWEETWATER ROAD	SPRING VALLEY	CA	91977	01/01/2018	06/01/2019
CH095440	THRIFTY PAYLESS, INC.	RITE AID #5623	2516 JAMACHA ROAD	EL CAJON	CA	92019	01/01/2018
CH095440	US BIOSERVICES	PHARM PLUS ACQUISITION, INC.	5100 E HUNTER AVE SUITE 101	ANAHEIM	CA	92807-2049	04/01/2019
CH095440	US BIOSERVICES	US BIOSERVICE CORPORATION	5025 PLANO PARKWAY STE 100	CARROLLTON	TX	75010	04/01/2019
CH095440	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/01/2018
CH095440	WAL-MART PHARMACY 10-2150	710 DENNERY RD		SAN DIEGO	CA	92154	01/01/2018
CH095440	WAL-MART PHARMACY 10-2253	13487 CAMINO CANADA		EL CAJON (EAST)	CA	92021	01/01/2018
CH095440	WAL-MART PHARMACY 10-3516	1360 EASTLAKE PKWY		CHULA VISTA(E)	CA	91915	01/01/2018
CH095440	WAL-MART PHARMACY 10-3524	605 FLETCHER PKWY		EL CAJON (C)	CA	92020	01/01/2018
CH095440	WAL-MART PHARMACY 10-5023	1200 HIGHLAND AVE		NATIONAL CITY	CA	91950	01/01/2018
CH095440	WAL-MART PHARMACY 10-5315	2354 COMMERCE PARK DR.		ORLANDO	FL	32819	01/01/2018
CH095440	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/01/2018
CH095440	WALGREEN CO.	DBA: WALGREENS #13161	4029 43RD ST. STE 700	SAN DIEGO	CA	92105	07/01/2017
CH095440	WALGREEN CO.	DBA: WALGREENS # 05844	215 NORTH 2ND STREET	EL CAJON	CA	92021	07/01/2017
CH095440	WALGREEN CO.	DBA: WALGREENS # 07869	885 EUCLID AVE	NATIONAL CITY	CA	91950	07/01/2017
CH095440	WALGREEN CO.	DBA: WALGREENS #11654	10787 CAMINO RUIZ	SAN DIEGO	CA	92126-2304	07/01/2017
CH095440	WALGREEN CO.	DBA: WALGREENS # 06656	3222 UNIVERSITY AVENUE	SAN DIEGO	CA	92104-2010	07/01/2017	01/10/2024
CH095440	WALGREEN CO.	DBA: WALGREENS #12915	7195 BROADWAY	LEMON GROVE	CA	91945-1408	07/01/2017
CH095440	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #13434	640 UNIVERSITY AVE	SAN DIEGO	CA	92103	01/01/2018
CH095440	WALMART PHARMACY #10-4169	300 N. 2ND ST		EL CAJON	CA	92021	01/01/2018
CH095440	WESTERN PHARMACY GROUP LLC	DBA MEDICAL CENTER PHARMACY	4074 FAIRMOUNT AVE	SAN DIEGO	CA	92105-1608	07/01/2018
CH095440	WESTERN PHARMACY GROUP LLC	DBA MEDICAL CENTER PHARMACY	286 EUCLID AVE STE 206	SAN DIEGO	CA	92114-3612	07/01/2018
CH095440	WESTERN PHARMACY GROUP LLC	DBA GALLOWAY'S MEDICAL CENTER PHARMACY	2995 NATIONAL AVE	SAN DIEGO	CA	92113-2419	07/01/2018
CH095440	WESTERN PHARMACY GROUP LLC	DBA COMMUNITY MEDICAL CENTER PHARMACY	610 GATEWAY CENTER WAY SUITES A--E	SAN DIEGO	CA	92102	07/01/2018
CH095440	WESTERN PHARMACY GROUP LLC	DBA MEDICAL CENTER PHARMACY	3904 PARK BLVD	SAN DIEGO	CA	92103-3502	07/01/2018
CH095440	WESTERN PHARMACY GROUP LLC	DBA MEDICAL CENTER PHARMACY	340 4TH AVE STE 1	CHULA VISTA	CA	91910-3882	07/01/2018
CH095440	WESTERN PHARMACY GROUP LLC	DBA MEDICAL CENTER PHARMACY	480 4TH AVE STE 100	CHULA VISTA	CA	91910-4411	07/01/2018

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	2/1/2024 9:52:45 PM	2/12/2025 10:13:56 PM	2/12/2025 10:13 PM
Details	Last Recertification Date	Update	Recertification	2/3/2023 1:58:16 PM	2/1/2024 9:52:45 PM	2/1/2024 9:52 PM
Details	Last Recertification Date	Update	Recertification	1/31/2022 10:01:44 PM	2/3/2023 1:58:16 PM	2/3/2023 1:58 PM
Details	Last Recertification Date	Update	Recertification	2/10/2021 7:03:09 PM	1/31/2022 10:01:44 PM	1/31/2022 10:01 PM
Contacts	Primary Contact	Update	Profile Change Request	Vu, Tom Chief of Risk Management and Corporate Compliance La Maestra Family Clinic, Inc. 6195841612-3011	Vu, Tom Executive Director La Maestra Family Clinic, Inc. 6199724165	1/26/2022 1:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/10/2021 7:03 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		FHC70472G	2/10/2021 7:03 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	2/10/2021 7:03 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	2/10/2021 7:03 PM
Details	Last Recertification Date	Update	Recertification	2/3/2020 8:07:27 AM	2/10/2021 7:03:09 PM	2/10/2021 7:03 PM
Contacts	Primary Contact	Update	Recertification	Jones, Byron Pharmacy Director La Maestra Family Clinic, Inc. 6195647013	Vu, Tom Chief of Risk Management and Corporate Compliance La Maestra Family Clinic, Inc. 6195841612-3011	2/3/2020 8:07 AM
Details	Last Recertification Date	Update	Recertification	2/13/2019 12:56:02 PM	2/3/2020 8:07:27 AM	2/3/2020 8:07 AM
Details	Last Recertification Date	Update	Recertification	2/14/2018 6:08:14 PM	2/13/2019 12:56:02 PM	2/13/2019 12:56 PM
Details	Last Recertification Date	Update	Recertification		2/14/2018 6:08:14 PM	2/14/2018 6:08 PM
Details	State	Update		Approved	Active	1/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		MARSELIAN, ZARA CEO La Maestra Family Clinic, Inc. 6195841612-3018	12/12/2017 1:56 PM
Details	340B ID	Update	New Registration		CH09544AC	12/12/2017 1:56 PM
Dates	Participating Approval Date	Update	New Registration		12/12/2017 1:56:04 PM	12/12/2017 1:56 PM
Details	State	Update	New Registration	Pending	Approved	12/12/2017 1:56 PM
Dates	Signed By Date	Update	New Registration		12/12/2017 1:16:08 PM	12/12/2017 1:56 PM
Dates	Start Date	Update	New Registration		1/1/2018 12:00:00 AM	12/12/2017 1:56 PM
Addresses	Main Address	Insert	New Registration		4474 El Cajon Blvd San Diego, CA 92115-4312	12/12/2017 11:04 AM
Addresses	Billing Address	Insert	New Registration		La Maestra Family Clinic, Inc. 4060 Fairmount Ave San Diego, CA 92105	12/12/2017 11:04 AM
Addresses	Shipping Address	Insert	New Registration		La Maestra Family Clinic, Inc. 4060 Fairmount Ave San Diego, CA 92105	12/12/2017 11:04 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1609849074	12/12/2017 11:04 AM
Contacts	Primary Contact	Insert	New Registration		Jones, Byron Pharmacy Director La Maestra Family Clinic, Inc. 6195647013	12/12/2017 11:04 AM
Contacts	Authorizing Official	Insert	New Registration		MARSELIAN, ZARA CEO La Maestra Family Clinic, Inc. 6195841612-3018	12/12/2017 11:04 AM
Details	Last Recertification Date	Insert	New Registration			12/12/2017 11:04 AM
Details	Grant Number	Insert	New Registration		H80CS00812	12/12/2017 11:04 AM
Details	340B ID	Insert	New Registration			12/12/2017 11:04 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			12/12/2017 11:04 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			12/12/2017 11:04 AM
Details	Medicare Provider Number	Insert	New Registration			12/12/2017 11:04 AM
Details	Entity Name	Insert	New Registration		La Maestra Family Clinic, Inc.	12/12/2017 11:04 AM
Details	Program Code	Insert	New Registration		CH	12/12/2017 11:04 AM
Details	Entity Subname	Insert	New Registration		La Maestra Hoover High School Medical and Dental Clinic	12/12/2017 11:04 AM
Dates	Participating Approval Date	Insert	New Registration			12/12/2017 11:04 AM
Details	State	Insert	New Registration		Pending	12/12/2017 11:04 AM
Dates	Registration Date	Insert	New Registration		12/12/2017 11:04:51 AM	12/12/2017 11:04 AM
Dates	Signed By Date	Insert	New Registration			12/12/2017 11:04 AM
Dates	Start Date	Insert	New Registration			12/12/2017 11:04 AM
Terminations	Termination Comments	Insert	New Registration			12/12/2017 11:04 AM
Terminations	Termination Date	Insert	New Registration			12/12/2017 11:04 AM
Terminations	Termination Effective Date	Insert	New Registration			12/12/2017 11:04 AM
Terminations	Termination Reason	Insert	New Registration			12/12/2017 11:04 AM

340B Drug Pricing Program Database