Covered Entity Details

CHC22689-05 MARIN CITY HEALTH AND WELLNESS CENTER (Terminated) - information as of 6/12/2025 9:47:12 PM

Main Details

Name

MARIN CITY HEALTH AND WELLNESS CENTER

Subdivision Name

Dr. George W. Davis Senior Center

Type

HRSA-Funded Health Center

Site ID

BPS-H80-021562

340B ID

CHC22689-05

Grant Number

H80CS22689

Additional Details

Current Program Status

Terminated

Registration Date

3/7/2018

Participating Start Date

4/1/2018

Participating Approval Date

3/7/2018

Last Recertification Date

3/10/2021

Termination Date
Termination Reason

4/1/2022
Business decision by the Covered Entity

Contacts

Authorizing Official

Marin City Health and Wellness Center
Randi Ganousis, Federal Grants Manager
(314) 757-6788

Primary Contact

Marin City Health and Wellness Center
Lisa Monique Hubbard-Griffith, Executive Assistant
(415) 579-0077

Addresses

Street Address

1751 Carroll Ave
San Francisco, CA 94124-2898

Billing Address

Marin City Health and Wellness Center
630 Drake Avenue
Marin City, CA 94965

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	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
CHC22689-00	Active	BPS-H80-010788	MARIN CITY HEALTH AND WELLNESS CENTER	Marin City Health & Wellness Center	630 Drake Avenue	Marin City	CA
CHC22689-01	Active	BPS-H80-017484	MARIN CITY HEALTH AND WELLNESS CENTER	Bayview Hunters Point Clinic	6301 3rd Street	San Francisco	CA
CHC22689-02	Active	BPS-H80-021381	MARIN CITY HEALTH AND WELLNESS CENTER	Women's Health Clinic	880 Las Gallinas, Suite 1	San Rafael	CA
CHC22689-03	Terminated	BPS-H80-012736	MARIN CITY HEALTH AND WELLNESS CENTER	Health Care for the Homeless Clinic - Center Point	1601 2nd St	San Rafael	CA
CHC22689-04	Active	BPS-H80-018085	MARIN CITY HEALTH AND WELLNESS CENTER	Marin City Health and Wellness Dental Van	630 Drake Avenue	Marin City	CA
CHC22689-05	Terminated	BPS-H80-021562	MARIN CITY HEALTH AND WELLNESS CENTER	Dr. George W. Davis Senior Center	1751 Carroll Ave	San Francisco	CA
CHC22689-06	Terminated	BPS-H80-020881	MARIN CITY HEALTH AND WELLNESS CENTER	Perinatal & Women's Health Suite	880 Las Gallinas Suite #2	San Rafael	CA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17623	789 MISSION ST	SAN FRANCISCO	CA	94103	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY # 17709	233 WINSTON DRIVE	SAN FRANCISCO	CA	94132	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16439	1150 EL CAMINO REAL	SAN BRUNO	CA	94066	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10368	400 SUTTER ST.	SAN FRANCISCO	CA	94108	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10188	499 HAIGHT STREET	SAN FRANCISCO	CA	94117	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10330	3600 GEARY BLVD	SAN FRANCISCO	CA	94118	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY # 17694	180 DONAHUE STREET	SAUSALITO	CA	94965	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY # 7657	351 CALIFORNIA STREET	SAN FRANCISCO	CA	94104	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY # 10035	581 MARKET ST	SAN FRANCISCO	CA	94105	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10165	135 PIERCE STREET	DALY CITY	CA	94015	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY #11107	701 VAN NESS AVENUE	SAN FRANCISCO	CA	94102	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #4770	1101 MARKET STREET	SAN FRANCISCO	CA	94103	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY # 2852	731 MARKET ST.	SAN FRANCISCO	CA	94103	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10164	601 MISSION STREET	SAN FRANCISCO	CA	94105	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16111	5001 JUNIPERO SERRA BLVD	COLMA	CA	94014	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #5131	1900 19TH AVENUE	SAN FRANCISCO	CA	94116	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY # 10080	1059 HYDE ST.	SAN FRANCISCO	CA	94109	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY# 1983	701 PORTOLA DR	SAN FRANCISCO	CA	94127	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16746	133 SERRAMONTE CTR	DALY CITY	CA	94015	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY # 1483	1599 TIBURON BLVD	TIBURON	CA	94920	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY #10495	399 GEARY STREET	SAN FRANCISCO	CA	94102	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17625	2675 GEARY BLVD	SAN FRANCISCO	CA	94118	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY # 10492	500 PINE ST	SAN FRANCISCO	CA	94108	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17674	1830 OCEAN AVE	SAN FRANCISCO	CA	94112	04/01/2020
CHC22689-00	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17672	225 BUSH ST. #100	SAN FRANCISCO	CA	94104	04/01/2020
CHC22689-00	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09913	759 E BLITHEDALE AVE	MILL VALLEY	CA	94941	04/01/2020
CHC22689-00	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 07955	2025 VAN NESS AVE	SAN FRANCISCO	CA	94109	04/01/2020
CHC22689-00	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09962	150 DONAHUE ST	SAUSALITO	CA	94965	04/01/2020

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		12/31/2020 12:00:00 AM	2/11/2022 9:02 AM
Details	State	Update	Recertification	Active	To Be Terminated	2/11/2022 9:02 AM
Terminations	Termination Comments	Update	Recertification		This site was used temporarily while we renovated our Bayview Clinic. Marin City Health and Wellness Center is no longer providing any services from this site.	2/11/2022 9:02 AM
Terminations	Termination Date	Update	Recertification		4/1/2022 12:00:00 AM	2/11/2022 9:02 AM
Terminations	Termination Effective Date	Update	Recertification		12/31/2020 12:00:00 AM	2/11/2022 9:02 AM
Terminations	Termination Reason	Update	Recertification		Business decision by the Covered Entity	2/11/2022 9:02 AM
Contacts	Authorizing Official	Update	AO Change Request	Wallace, Harold CEO Marin City Health and Wellness Center 4153398813-162	Ganousis, Randi Federal Grants Manager Marin City Health and Wellness Center 3147576788	2/11/2022 8:35 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1285804948 (CA)		3/10/2021 7:23 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1285804948 ( )		3/10/2021 7:23 AM
Contacts	Primary Contact	Update	Recertification	Rodriguez, Patricia Chief Operating Officer Marin City Health and Wellness Center 4153398813	Hubbard-Griffith, Lisa Monique Executive Assistant Marin City Health and Wellness Center 4155790077	3/10/2021 7:23 AM
Details	Last Recertification Date	Update	Recertification	2/18/2020 3:08:33 PM	3/10/2021 7:23:29 AM	3/10/2021 7:23 AM
Contacts	Authorizing Official	Update	AO Change Request	Paulucci-Whiting, Brenda Chief Operating Officer Marin City Health and Wellness Center 9173067647	Wallace, Harold CEO Marin City Health and Wellness Center 4153398813-162	1/31/2021 11:16 AM
Details	Last Recertification Date	Update	Recertification	2/7/2019 11:08:29 AM	2/18/2020 3:08:33 PM	2/18/2020 3:08 PM
Contacts	Authorizing Official	Update	AO Change Request	Jordan, Khailylah Interim CEO Marin City Health and Wellness Center 4153398813	Paulucci-Whiting, Brenda Chief Operating Officer Marin City Health and Wellness Center 9173067647	10/25/2019 8:06 AM
Details	Last Recertification Date	Update	Recertification		2/7/2019 11:08:29 AM	2/7/2019 11:08 AM
Contacts	Authorizing Official	Update	AO Change Request	Muhammad, Jayvon Executive Director Marin City Health and Wellness Center 4153398813	Jordan, Khailylah Interim CEO Marin City Health and Wellness Center 4153398813	2/7/2019 10:59 AM
Details	State	Update		Approved	Active	4/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		Muhammad, Jayvon Executive Director Marin City Health and Wellness Center 4153398813	3/7/2018 1:04 PM
Details	340B ID	Update	New Registration		CHC22689-05	3/7/2018 1:04 PM
Dates	Participating Approval Date	Update	New Registration		3/7/2018 1:04:50 PM	3/7/2018 1:04 PM
Details	State	Update	New Registration	Pending	Approved	3/7/2018 1:04 PM
Dates	Signed By Date	Update	New Registration		3/7/2018 11:27:16 AM	3/7/2018 1:04 PM
Dates	Start Date	Update	New Registration		4/1/2018 12:00:00 AM	3/7/2018 1:04 PM
Addresses	Main Address	Insert	New Registration		1751 Carroll Ave San Francisco, CA 94124-2898	3/7/2018 11:27 AM
Addresses	Billing Address	Insert	New Registration		Marin City Health and Wellness Center 630 Drake Avenue Marin City, CA 94965	3/7/2018 11:27 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	3/7/2018 11:27 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1285804948	3/7/2018 11:27 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	3/7/2018 11:27 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1285804948	3/7/2018 11:27 AM
Contacts	Authorizing Official	Insert	New Registration		Muhammad, Jayvon Executive Director Marin City Health and Wellness Center 4153398813	3/7/2018 11:27 AM
Contacts	Primary Contact	Insert	New Registration		Rodriguez, Patricia Chief Operating Officer Marin City Health and Wellness Center 4153398813	3/7/2018 11:27 AM
Details	Last Recertification Date	Insert	New Registration			3/7/2018 11:27 AM
Details	Grant Number	Insert	New Registration		H80CS22689	3/7/2018 11:27 AM
Details	340B ID	Insert	New Registration			3/7/2018 11:27 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			3/7/2018 11:27 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			3/7/2018 11:27 AM
Details	Medicare Provider Number	Insert	New Registration			3/7/2018 11:27 AM
Details	Entity Name	Insert	New Registration		MARIN CITY HEALTH AND WELLNESS CENTER	3/7/2018 11:27 AM
Details	Program Code	Insert	New Registration		CH	3/7/2018 11:27 AM
Details	Entity Subname	Insert	New Registration		Dr. George W. Davis Senior Center	3/7/2018 11:27 AM
Dates	Participating Approval Date	Insert	New Registration			3/7/2018 11:27 AM
Details	State	Insert	New Registration		Pending	3/7/2018 11:27 AM
Dates	Registration Date	Insert	New Registration		3/7/2018 11:27:13 AM	3/7/2018 11:27 AM
Dates	Signed By Date	Insert	New Registration			3/7/2018 11:27 AM
Dates	Start Date	Insert	New Registration			3/7/2018 11:27 AM
Terminations	Termination Comments	Insert	New Registration			3/7/2018 11:27 AM
Terminations	Termination Date	Insert	New Registration			3/7/2018 11:27 AM
Terminations	Termination Effective Date	Insert	New Registration			3/7/2018 11:27 AM
Terminations	Termination Reason	Insert	New Registration			3/7/2018 11:27 AM

340B Drug Pricing Program Database