Covered Entity Details

CHC26566-19 Jane Pauley Community Health Center, Inc. (Terminated) - information as of 5/9/2025 10:50:18 PM

Main Details

Name

Jane Pauley Community Health Center, Inc.

Subdivision Name

Jane Pauley Community Health Center at St. Mary School

Type

HRSA-Funded Health Center

Site ID

BPS-H80-020791

340B ID

CHC26566-19

Grant Number

H80CS26566

Additional Details

Current Program Status

Terminated

Registration Date

7/13/2018

Participating Start Date

10/1/2018

Participating Approval Date

8/24/2018

Last Recertification Date

1/30/2023

Termination Date
Termination Reason

10/1/2023
Business decision by the Covered Entity

Contacts

Authorizing Official

Jane Pauley Community Health Center
Dale Marion, 340B Program Manager
(317) 552-0690

Primary Contact

Jane Pauley CHC
Michael Dale, CFO
(317) 934-0751

Addresses

Street Address

820 West Madison Avenue Zimmerman Hall
Alexandria, IN 46001

Billing Address

Jane Pauley Community Health Center, Inc.
1503 N. Mitthoeffer Road
Indianapolis, IN 46229

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
CHC26566-00	Active	BPS-H80-013290	JANE PAULEY COMMUNITY HEALTH CENTER, INC.	Jane Pauley Community Health Center	8931 E. 30th Street	Indianapolis	IN
CHC26566-01	Terminated	BPS-H80-013110	JANE PAULEY COMMUNITY HEALTH CENTER, INC.	Jane Pauley Center at Howe	4900 Julian Ave	Indianapolis	IN
CHC26566-02	Terminated	BPS-H80-013082	JANE PAULEY COMMUNITY HEALTH CENTER, INC.	Jane Pauley Community Health Center Dental Clinic	9651 E 21st St	Indianapolis	IN
CHC26566-03	Terminated	BPS-H80-013109	JANE PAULEY COMMUNITY HEALTH CENTER, INC.	Jane Pauley Center at Hawthorne Elementary	8301 Rawles Ave	Indianapolis	IN
CHC26566-04	Terminated	BPS-H80-013301	JANE PAULEY COMMUNITY HEALTH CENTER, INC.	Jane Pauley Community Health Center at Brook Park	5259 David St	Indianapolis	IN
CHC26566-05	Terminated	BPS-H80-013269	JANE PAULEY COMMUNITY HEALTH CENTER, INC.	Jane Pauley Center at Shelbyville	1200 W Mckay Rd	Shelbyville	IN
CHC26566-06	Active	BPS-H80-013254	JANE PAULEY COMMUNITY HEALTH CENTER, INC.	Jane Pauley Center at Shadeland	2040 N Shadeland Ave STE 300	Indianapolis	IN
CHC26566-07	Terminated	BPS-H80-013938	JANE PAULEY COMMUNITY HEALTH CENTER, INC.	Jane Pauley Community Health Center at Gallahue	5470 E 16TH ST	INDIANAPOLIS	IN
CHC26566-08	Active	BPS-H80-013890	JANE PAULEY COMMUNITY HEALTH CENTER, INC.	Jane Pauley Community Health Center at Anderson	1210 Medical Arts Boulevard, Suite 300	Anderson	IN
CHC26566-09	Active	BPS-H80-013886	JANE PAULEY COMMUNITY HEALTH CENTER, INC.	Jane Pauley Community Health Center at Greenfield	1107 N STATE ST	GREENFIELD	IN
CHC26566-10	Active	BPS-H80-013885	JANE PAULEY COMMUNITY HEALTH CENTER, INC.	Jane Pauley Community Health Center at 16th Street	5317 E 16TH ST	INDIANAPOLIS	IN
CHC26566-11	Active	BPS-H80-013533	JANE PAULEY COMMUNITY HEALTH CENTER, INC.	Jane Pauley Community Health Center Administraive Offices	1503 N MITTHOEFFER RD	INDIANAPOLIS	IN
CHC26566-12	Terminated	BPS-H80-017046	JANE PAULEY COMMUNITY HEALTH CENTER, INC.	Jane Pauley Community Health Center at Madison Avenue	8320 Madison Avenue	Indianapolis	IN
CHC26566-13	Active	BPS-H80-017652	JANE PAULEY COMMUNITY HEALTH CENTER, INC.	Jane Pauley Community Health Center at the Wigwam	1229 Lincoln Street	Anderson	IN
CHC26566-14	Terminated	BPS-H80-017651	JANE PAULEY COMMUNITY HEALTH CENTER, INC.	Jane Pauley Community Health Center at Ebbertt	325 W. 38th Street	Anderson	IN
CHC26566-15	Active	BPS-H80-017650	JANE PAULEY COMMUNITY HEALTH CENTER, INC.	Jane Pauley Community Health Center at Alexandria	121 W. Washington Street	Alexandria	IN
CHC26566-16	Active	BPS-H80-036469	JANE PAULEY COMMUNITY HEALTH CENTER, INC.	Jane Pauley Community Health Center at Shelbyville IN 44	1818 E. State Road 44, Suite B	Shelbyville	IN
CHC26566-17	Active	BPS-H80-021296	Jane Pauley Community Health Center, Inc.	Jane Pauley Community Health Center at Arlington	1315 N Arlington Ave	Indianapolis	IN
CHC26566-18	Terminated	BPS-H80-020788	Jane Pauley Community Health Center, Inc.	Jane Pauley Community Health Center at Holy Cross South Campus School	2825 Lincoln Street Resource Room	Anderson	IN
CHC26566-19	Terminated	BPS-H80-020791	Jane Pauley Community Health Center, Inc.	Jane Pauley Community Health Center at St. Mary School	820 West Madison Avenue Zimmerman Hall	Alexandria	IN
CHC26566-20	Terminated	BPS-H80-020789	Jane Pauley Community Health Center, Inc.	Jane Pauley Community Health Center at Holy Cross North Campus School	1115 Pearl Street Room 209	Anderson	IN
CHC26566-21	Active	BPS-H80-020787	Jane Pauley Community Health Center, Inc.	Jane Pauley Community Health Center at Alexandria-Monroe Junior-Senior High School	1 Burden Court Room #16	Alexandria	IN
CHC26566-22	Active	BPS-H80-020911	Jane Pauley Community Health Center, Inc.	Jane Pauley Community Health Center at Alexandria-Monroe Intermediate School	308 W. 11th Street Room G-1	Alexandria	IN
CHC26566-23	Active	BPS-H80-022278	Jane Pauley Community Health Center, Inc.	Jane Pauley Community Health Center at Castleton	7481 N. Shadeland Avenue, Suite A	Indianapolis	IN
CHC26566-24	Terminated	BPS-H80-024639	Jane Pauley Community Health Center, Inc.	Jane Pauley Community Health Center at Smith Valley Road	1664 Smith Valley Road	Greenwood	IN
CHC26566-25	Active	BPS-H80-035627	JANE PAULEY COMMUNITY HEALTH CENTER INC	Jane Pauley Community Health Center Administrative Site at Arlington	1311 N Arlington Avenue	Indianapolis	IN
CHC26566-26	Active	BPS-H80-038314	Jane Pauley Community Health Center, Inc.	Jane Pauley Community Health Center at Washington Street	7910 E Washington St, Ste 300	Indianapolis	IN
CHC26566-27	Active	BPS-H80-038278	Jane Pauley Community Health Center, Inc.	Jane Pauley Community Health Center at Reed Street Kokomo	3611 S Reed Rd	Kokomo	IN
CHC26566-28	Active	BPS-H80-038262	Jane Pauley Community Health Center, Inc.	Jane Pauley Community Health Center at 1629 Anderson	1629 Medical Arts Blvd	Anderson	IN
CHC26566-29	Active	BPS-H80-038277	Jane Pauley Community Health Center, Inc.	Jane Pauley Community Health Center at County Line Road Greenwood	333 E County Line Rd	Greenwood	IN
CHC26566-30	ToBeTerminated	BPS-H80-038276	Jane Pauley Community Health Center, Inc.	Jane Pauley Community Health Center at LaFountain Street Kokomo	3510 S Lafountain St	Kokomo	IN

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CHC26566-00	ACARIAHEALTH PHARMACY #26, INC	8715 HENDERSON RD		TAMPA	FL	33634	07/01/2024	11/01/2024
CHC26566-00	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	01/01/2024
CHC26566-00	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	01/01/2024
CHC26566-00	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	01/01/2024
CHC26566-00	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	01/01/2024
CHC26566-00	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	01/01/2024
CHC26566-00	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	01/01/2024
CHC26566-00	BIOPLUS SPECIALTY PHARMACY LA, LLC	2731 MANHATTAN BLVD STE B17		HARVEY	LA	70058	04/01/2024
CHC26566-00	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	04/01/2024
CHC26566-00	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	04/01/2024
CHC26566-00	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	13925 YALE AVE STE 145		IRVINE	CA	92620-2670	04/01/2024
CHC26566-00	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4740 VICTORY LN STE C	INDIANAPOLIS	IN	46203	04/01/2025
CHC26566-00	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	145 S 79TH ST STE 70	CHANDLER	AZ	85226	04/01/2025
CHC26566-00	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	04/01/2022
CHC26566-00	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/01/2022
CHC26566-00	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/01/2022
CHC26566-00	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	04/01/2022
CHC26566-00	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	04/01/2022
CHC26566-00	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/01/2022
CHC26566-00	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	04/01/2022
CHC26566-00	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/01/2022
CHC26566-00	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/01/2022
CHC26566-00	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	04/01/2022
CHC26566-00	CENTERWELL PHARMACY, INC.	9843 WINDISCH RD		WEST CHESTER	OH	45069	07/01/2024
CHC26566-00	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	07/01/2023
CHC26566-00	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	07/01/2023
CHC26566-00	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	04/01/2022
CHC26566-00	CYSTIC FIBROSIS SERVICES	CYSTIC FIBROSIS SERVICES, INC	10530 JOHN W ELLIOTT DR, STE 200	FRISCO	TX	75033	01/01/2023	01/01/2023
CHC26566-00	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	01/01/2023
CHC26566-00	DOGWOOD PHARMACY LLC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER RD STE K	GREENVILLE	SC	29607-6541	04/01/2024
CHC26566-00	EAST SIDE PRESCRIPTION SHOP	5317 EAST 16TH STREET		INDIANAPOLIS	IN	46218	04/01/2018	07/31/2019
CHC26566-00	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	01/01/2024
CHC26566-00	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	01/01/2024
CHC26566-00	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	01/01/2024
CHC26566-00	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	01/01/2024
CHC26566-00	FOUNDATION CARE LLC	111 CHESTERFIELD INDUSTRIAL BLVD STE 115		CHESTERFIELD	MO	63005	07/01/2024
CHC26566-00	GENOA HEALTHCARE LLC	2009 BROWN STREET	SUITE 7	ANDERSON	IN	46016-4216	01/01/2024
CHC26566-00	GENOA HEALTHCARE LLC	6655 EAST US HIGHWAY 36		AVON	IN	46123	01/01/2024
CHC26566-00	GENOA HEALTHCARE LLC	5470 E 16TH STREET SUITE 150		INDIANAPOLIS	IN	46218	10/01/2024
CHC26566-00	GEORGE'S PHARMACY EAST SIDE, LLC	5543 E WASHINGTON ST		INDIANAPOLIS	IN	46219	07/01/2021
CHC26566-00	HOMESCRIPTS	12968 PAULINE DR		SHELBY TOWNSHIP	MI	48315	07/01/2024
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06613	4401 E. 10TH ST.	INDIANAPOLIS	IN	46201	04/01/2018
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 08643	1030 N ARLINGTON AVE	INDIANAPOLIS	IN	46219	04/01/2018
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 00045	6975 N. PENDLETON PIKE	INDIANAPOLIS	IN	46226	01/01/2019
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 04633	1233 NORTH STATE ST.	GREENFIELD	IN	46140	01/01/2019
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 05423	7935 BROOKVILLE RD.	INDIANAPOLIS	IN	46239	01/01/2019
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06592	6005 EAST WASHINGTON STREET	INDIANAPOLIS	IN	46219	01/01/2019	08/01/2020
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06594	8935 EAST 21ST STREET	INDIANAPOLIS	IN	46219	01/01/2019
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06595	3808 EAST WASHINGTON ST	INDIANAPOLIS	IN	46201	01/01/2019
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06637	200 S. HARRISON	SHELBYVILLE	IN	46176	01/01/2019
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06640	265 SO. SCATTERFIELD RD	ANDERSON	IN	46012	01/01/2019
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06651	2003 BROADWAY	ANDERSON	IN	46012	01/01/2019
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06661	263 W MORGAN ST.	KNIGHTSTOWN	IN	46148	01/01/2019
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06612	5110 E. 38TH ST.	INDIANAPOLIS	IN	46218	01/01/2019
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06583	1715 MAIN STREET	BEECH GROVE	IN	46107	07/01/2019
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06616	425 E MEMORIAL DR	MUNCIE	IN	47302	07/01/2019
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06618	105 NORTH PARK AVE	ALEXANDRIA	IN	46001	07/01/2019
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06617	100 N ANDERSON ST.	ELWOOD	IN	46036	07/01/2019
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 02311	2215 SOUTH SHELBY STREET	INDIANAPOLIS	IN	46203	07/01/2019
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 07052	2029 W WASHINGTON ST	INDIANAPOLIS	IN	46222	07/01/2019	10/31/2020
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 03297	4935 S. ARLINGTON	INDIANAPOLIS	IN	46237	04/01/2020
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06549	1545 NORTH MERIDIAN ST.	INDIANAPOLIS	IN	46202	04/01/2020
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06566	2550 CONNER ST.	NOBLESVILLE	IN	46060	04/01/2020
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06573	2330 EAST 46TH ST.	INDIANAPOLIS	IN	46205	04/01/2020
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06585	5605 NORTH POST RD.	INDIANAPOLIS	IN	46216	04/01/2020
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06599	715 E. BROADWAY	FORTVILLE	IN	46040	04/01/2020
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06600	1530 N. SHADELAND AVE.	INDIANAPOLIS	IN	46219	04/01/2020
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06605	9550 ALLISONVILLE RD.	INDIANAPOLIS	IN	46250	04/01/2020
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06608	5026 WEST US 52	NEW PALESTINE	IN	46163	04/01/2020
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06623	201 S. TILLOTSON AVENUE	MUNCIE	IN	47304	04/01/2020
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06638	2419 NICHOL AVE	ANDERSON	IN	46016	04/01/2020
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06645	101 WEST 1ST ST.	RUSHVILLE	IN	46173	04/01/2020
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06654	8970 S. MERIDIAN ST.	INDIANAPOLIS	IN	46217	04/01/2020
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06656	3824 MAIN STREET	ANDERSON	IN	46013	04/01/2020
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06663	11 NORTH MORTON STREET	FRANKLIN	IN	46131	04/01/2020
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 07634	3805 N. GERMAN CHURCH RD.	INDIANAPOLIS	IN	46235	04/01/2020
CHC26566-00	HOOK-SUPERX, L.L.C.	CVS PHARMACY # 16569	10202 E WASHINGTON ST	INDIANAPOLIS	IN	46229	04/01/2020
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06643	220 S. MEMORIAL DR.	NEW CASTLE	IN	47362	01/01/2021
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06644	640 SOUTH STATE ROAD 135	GREENWOOD	IN	46142	01/01/2021
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06603	5005 EAST 56TH ST.	INDIANAPOLIS	IN	46226	04/01/2021
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06556	651 EAST MAIN STREET	DANVILLE	IN	46122	10/01/2021
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06662	711 W. MILL ST.	MIDDLETOWN	IN	47356	10/01/2021
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA CVS/PHARMACY # 3007	6010 SOUTH EMERSON AVENUE	INDIANAPOLIS	IN	46237	01/01/2023
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06597	10001 EAST WASHINGTON ST	INDIANAPOLIS	IN	46229	01/01/2023
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY #06622	1700 N. WALNUT ST	HARTFORD CITY	IN	47348	01/01/2023
CHC26566-00	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06658	620 E. STATE ST.	PENDLETON	IN	46064	01/01/2023
CHC26566-00	HOOK-SUPERX, L.L.C.	CVS/PHARMACY #11114	2800 ENTERPRISE ST STE 5	INDIANAPOLIS	IN	46219-1106	01/01/2023
CHC26566-16	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06637	200 S. HARRISON	SHELBYVILLE	IN	46176	04/01/2024
CHC26566-15	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06618	105 NORTH PARK AVE	ALEXANDRIA	IN	46001	04/01/2024
CHC26566-11	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 00045	6975 N. PENDLETON PIKE	INDIANAPOLIS	IN	46226	01/01/2025
CHC26566-17	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 04633	1233 NORTH STATE ST.	GREENFIELD	IN	46140	01/01/2025
CHC26566-21	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06594	8935 EAST 21ST STREET	INDIANAPOLIS	IN	46219	01/01/2025
CHC26566-22	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06613	4401 E. 10TH ST.	INDIANAPOLIS	IN	46201	01/01/2025
CHC26566-25	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 08643	1030 N ARLINGTON AVE	INDIANAPOLIS	IN	46219	01/01/2025
CHC26566-26	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06638	2419 NICHOL AVE	ANDERSON	IN	46016	01/01/2025
CHC26566-27	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06612	5110 E. 38TH ST.	INDIANAPOLIS	IN	46218	01/01/2025
CHC26566-28	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06640	265 SO. SCATTERFIELD RD	ANDERSON	IN	46012	01/01/2025
CHC26566-29	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06585	5605 NORTH POST RD.	INDIANAPOLIS	IN	46216	01/01/2025
CHC26566-30	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06656	3824 MAIN STREET	ANDERSON	IN	46013	01/01/2025	07/01/2025
CHC26566-00	JPCHC PHARMACY LLC	5317 E 16TH ST		INDIANAPOLIS	IN	46218	01/01/2024
CHC26566-00	KROGER #J-820	4445 EAST 10TH STREET		INDIANAPOLIS	IN	46201	04/01/2019
CHC26566-00	KROGER COLUMBUS CENTRAL FILL #019	2270 RICKENBACKER PKWY W		COLUMBUS	OH	43217	01/01/2020
CHC26566-00	KROGER PHARMACY	1571 N. STATE STREET		GREENFIELD	IN	46140	04/01/2019
CHC26566-00	KROGER PHARMACY	#116	680 TWIN AIRE DRIVE	INDIANAPOLIS	IN	46203	04/01/2019
CHC26566-00	KROGER PHARMACY #995	5350 E. THOMPSON RD		INDIANAPOLIS	IN	46237	10/01/2019
CHC26566-00	KROGER PHARMACY CE 894	8745 SOUTH EMERSON AVENUE		INDIANAPOLIS	IN	46237	10/01/2020	12/31/2023
CHC26566-00	KROGER PHARMACY J-100	7101 E. 10TH STREET		INDIANAPOLIS	IN	46219	04/01/2019
CHC26566-00	KROGER PHARMACY J-804	5810 EAST 71ST STREET		INDIANAPOLIS	IN	46220	04/01/2019
CHC26566-00	KROGER PHARMACY J-862	11101 PENDLETON PIKE		INDIANAPOLIS	IN	46236	04/01/2019
CHC26566-00	KROGER PHARMACY J-974	1601 E MICHIGAN		SHELBYVILLE	IN	46176	04/01/2019
CHC26566-00	MEDWORKS PHARMACY	MEDWORKS INC	2123 INTELLIPLEX DR	SHELBYVILLE	IN	46176	04/01/2025
CHC26566-00	MEIJER DISTRIBUTION INC #90	2721 WALKER AVE NW		GRAND RAPIDS	MI	49544	07/01/2019	04/17/2020
CHC26566-00	MEIJER PHARMACY #131	11351 E. WASHINGTON ST		INDIANAPOLIS	IN	46229	07/01/2019	04/17/2020
CHC26566-00	MEIJER PHARMACY #136	6610 SCATTERFIELD RD		ANDERSON	IN	46013-9605	07/01/2019	04/17/2020
CHC26566-00	MEIJER PHARMACY #464	41255 COCA COLA DR.		BELLEVILLE	MI	48111-1827	07/01/2019	04/17/2020
CHC26566-00	MEIJER STORES LIMITED PARTNERSHIP	D/B/A MEIJER PHARMACY #463	1515 PROFIT DR.	FORT WAYNE	IN	46808	07/01/2019	04/17/2020
CHC26566-00	OPTUM PHARMACY 700, LLC	19 CHAPIN RD BLDG D, STE D8		PINE BROOK	NJ	07058	04/01/2024
CHC26566-00	OPTUM PHARMACY 700, LLC	5700 DOT COM CT, STE 1000		OVIEDO	FL	32765	04/01/2024
CHC26566-00	OPTUM PHARMACY 701, LLC	4015 SHOPTON RD STE 600		CHARLOTTE	NC	28217-3025	01/01/2024
CHC26566-00	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/01/2024
CHC26566-00	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	04/01/2024
CHC26566-00	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	10/01/2024
CHC26566-00	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	04/01/2024
CHC26566-00	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	04/01/2024
CHC26566-00	OPTUM PHARMACY 705, LLC	1893 GENERAL GEORGE PATTON DR	STE 106	FRANKLIN	TN	37067-2655	04/01/2024
CHC26566-00	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	04/01/2024
CHC26566-00	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	04/01/2024
CHC26566-00	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	04/01/2024
CHC26566-00	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	04/01/2024
CHC26566-00	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	04/01/2024
CHC26566-00	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	01/01/2024
CHC26566-00	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/01/2022
CHC26566-00	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	04/01/2022
CHC26566-00	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	04/01/2022
CHC26566-00	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	04/01/2024
CHC26566-00	REM CORPORATION	DBA COMMUNITY MEDICAL CENTER PHARM	1311 N. ARLINGTON AVE. SUITE 101	INDIANAPOLIS	IN	46219	01/01/2019	11/30/2019
CHC26566-00	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	04/01/2024
CHC26566-00	SANTA BARBARA SPECIALTY PHARMACY LLC	4690 CARPINTERIA AVE STE B		CARPINTERIA	CA	93013	04/01/2024
CHC26566-00	THE KROGER CO	#920	120 S MEMORIAL DR	NEW CASTLE	IN	47362	04/01/2019	12/31/2023
CHC26566-00	THE KROGER SAV-ON PHCY #945	10450 E WASHINGTON ST		INDIANAPOLIS	IN	46229	04/01/2019
CHC26566-00	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/01/2018
CHC26566-00	WAL-MART PHARMACY #10-1728	2321 CHARLES STREET		ANDERSON	IN	46013	07/01/2019
CHC26566-00	WAL-MART PHARMACY 10-0884	2500 PROGRESS PKWY		SHELBYVILLE	IN	46176	01/01/2025
CHC26566-30	WAL-MART PHARMACY 10-0884	2500 PROGRESS PKWY		SHELBYVILLE	IN	46176	01/01/2025	07/01/2025
CHC26566-00	WAL-MART PHARMACY 10-1141	1965 NORTH STATE STREET		GREENFIELD	IN	46140	04/01/2018
CHC26566-00	WAL-MART PHARMACY 10-1557	8300 E. 96TH ST		FISHERS	IN	46037	07/01/2019
CHC26566-00	WAL-MART PHARMACY 10-1580	10617 E WASHINGTON		INDIANAPOLIS	IN	46229	01/01/2019
CHC26566-00	WAL-MART PHARMACY 10-1758	3167 S STATE RD #3		NEW CASTLE	IN	47362	10/01/2024
CHC26566-00	WAL-MART PHARMACY 10-2787	7325 NO. KEYSTONE AVENUE		INDIANAPOLIS (N)	IN	46240	10/01/2024
CHC26566-00	WAL-MART PHARMACY 10-3435	1133 NORTH EMERSON ROAD		GREENWOOD	IN	46143	10/01/2024
CHC26566-00	WAL-MART PHARMACY 10-3529	10735 PENDLETON PIKE		INDIANAPOLIS	IN	46236	07/01/2019
CHC26566-00	WAL-MART PHARMACY 10-5443	4650 SOUTH EMERSON AVE.		INDIANAPOLIS	IN	46203	07/01/2019
CHC26566-00	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/01/2018
CHC26566-00	WALGREEN CO	DBA: WALGREENS #10487	6745 E SOUTHPORT ROAD	INDIANAPOLIS	IN	46237-9728	10/01/2018
CHC26566-00	WALGREEN CO	DBA: WALGREENS #10606	8945 MADISON AVENUE	INDIANAPOLIS	IN	46227	10/01/2018	01/05/2023
CHC26566-00	WALGREEN CO	DBA: WALGREENS #10073	2400 W SYCAMORE STREET	KOKOMO	IN	46901	07/01/2024
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 02800	8905 E 10TH ST	INDIANAPOLIS	IN	46219	04/01/2014
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 09278	11025 E WASHINGTON ST	INDIANAPOLIS	IN	46229	04/01/2014	03/01/2024
CHC26566-00	WALGREEN CO.	DBA: WALGREENS #13874	985 N. ARLINGTON AVE	INDIANAPOLIS	IN	46219	04/01/2014
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 03194	9050 E. 38TH STREET	INDIANAPOLIS	IN	46235	04/01/2014	08/01/2018
CHC26566-00	WALGREEN CO.	DBA: WALGREENS #21381	2920 E 38TH ST	INDIANAPOLIS	IN	46218	07/01/2017
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 02798	3205 E WASHINGTON ST	INDIANAPOLIS	IN	46201	07/01/2017	11/04/2019
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 02956	1808 ALBANY ST	BEECH GROVE	IN	46107	07/01/2017
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 03065	4555 N SHADELAND AVE	INDIANAPOLIS	IN	46226	07/01/2017	11/09/2023
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 04592	700 US HIGHWAY 31 S	GREENWOOD	IN	46143	07/01/2017
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 05393	20 S. MORTON ST.	FRANKLIN	IN	46131	07/01/2017
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 06761	3736 S SCATTERFIELD RD	ANDERSON	IN	46013	07/01/2017
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 07174	1195 N STATE STREET	GREENFIELD	IN	46140-1207	07/01/2017
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 07788	320 S SCATTERFIELD RD	ANDERSON	IN	46012-3601	07/01/2017
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 09489	1010 EAST STATE RD 44	SHELBYVILLE	IN	46176-1770	07/01/2017	11/16/2023
CHC26566-00	WALGREEN CO.	DBA: WALGREENS SPECIALTY PHARMACY #16317	335 MASSACHUSETTS AVENUE	INDIANAPOLIS	IN	46204	07/01/2017
CHC26566-00	WALGREEN CO.	DBA: WALGREENS #21257	902 E HANNA AVE	INDIANAPOLIS	IN	46227	10/01/2018
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 03442	7506 N SHADELAND AVE	INDIANAPOLIS	IN	46250	10/01/2018
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 03609	5095 E. THOMPSON RD.	INDIANAPOLIS	IN	46237	10/01/2018	05/21/2025
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 05804	455 EAST EPLER AVE	INDIANAPOLIS	IN	46227	10/01/2018
CHC26566-00	WALGREEN CO.	WALGREENS #10929	1650 EAST RAYMOND STREET	INDIANAPOLIS	IN	46203-4143	10/01/2018	11/04/2019
CHC26566-00	WALGREEN CO.	DBA: WALGREENS #10973	1530 N MERIDIAN ST	INDIANAPOLIS	IN	46202	10/01/2018
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 15032	1290 N STATE RD 135	GREENWOOD	IN	46142	10/01/2018
CHC26566-00	WALGREEN CO.	WALGREENS #16443	26 N. ARSENAL AVE.	INDIANAPOLIS	IN	46201	10/01/2018	02/18/2021
CHC26566-00	WALGREEN CO.	DBA WALGREENS #16558	1400 N RITTER AVE. SUITE 140	INDIANAPOLIS	IN	46219	10/01/2018
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 05853	720 S STATE RD 135	GREENWOOD	IN	46143	07/01/2019
CHC26566-00	WALGREEN CO.	W002 DBA: WALGREENS #07690	100 N. MEMORIAL DR	NEW CASTLE	IN	47362	07/01/2019
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 05978	11020 PENDLETON PIKE	INDIANAPOLIS	IN	46236	07/01/2019
CHC26566-00	WALGREEN CO.	WALGREENS #16557	1550 E. COUNTY LINE ROAD SUITE 150	INDIANAPOLIS	IN	46227	05/04/2020
CHC26566-00	WALGREEN CO.	DBA WALGREENS #16559	7120 CLEARVISTA DR. SUITE 1900	INDIANAPOLIS	IN	46256	01/01/2021
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 09129	2380 PLEASANT ST	NOBLESVILLE	IN	46060-3623	01/01/2022
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 02931	5199 N KEYSTONE	INDIANAPOLIS	IN	46205	01/01/2022
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 03142	3455 MANN ROAD	INDIANAPOLIS	IN	46221	04/01/2022
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 07031	9240 ROCKVILLE RD	INDIANAPOLIS	IN	46234-2558	04/01/2022
CHC26566-08	WALGREEN CO.	DBA: WALGREENS # 07788	320 S SCATTERFIELD RD	ANDERSON	IN	46012-3601	04/01/2024
CHC26566-06	WALGREEN CO.	DBA: WALGREENS # 02800	8905 E 10TH ST	INDIANAPOLIS	IN	46219	04/01/2024
CHC26566-13	WALGREEN CO.	DBA: WALGREENS # 06761	3736 S SCATTERFIELD RD	ANDERSON	IN	46013	04/01/2024
CHC26566-09	WALGREEN CO.	DBA: WALGREENS # 07174	1195 N STATE STREET	GREENFIELD	IN	46140-1207	04/01/2024
CHC26566-23	WALGREEN CO.	DBA: WALGREENS # 03442	7506 N SHADELAND AVE	INDIANAPOLIS	IN	46250	04/01/2024
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 06944	3608 S LAFOUNTAIN STREET	KOKOMO	IN	46902-3809	07/01/2024
CHC26566-00	WALGREEN CO.	DBA: WALGREENS # 10074	2345 E MARKLAND AVE	KOKOMO	IN	46901-6245	07/01/2024
CHC26566-00	Walgreens Central Fill #21399	4132Plainfield Rd	Ste 110	Indianapolis	IN	46231-7021	04/01/2023
CHC26566-00	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	01/01/2023
CHC26566-00	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	01/01/2023
CHC26566-00	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	01/01/2023
CHC26566-00	WALMART PHARMACY #10-5767	9354 AMBLESIDE DRIVE		FISHERS	IN	46038	07/01/2019
CHC26566-00	WALMART PHARMACY #10-6390	5550 FALL CREEK PARKWAY N DRIVE		INDIANAPOLIS	IN	46226	07/01/2019
CHC26566-00	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	10/01/2024
CHC26566-00	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/01/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2023 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		12/31/2022 12:00:00 AM	8/17/2023 4:29 PM
Details	State	Update	Termination Request	Active	To Be Terminated	8/17/2023 4:29 PM
Terminations	Termination Date	Update	Termination Request		10/1/2023 12:00:00 AM	8/17/2023 4:29 PM
Terminations	Termination Effective Date	Update	Termination Request		3/31/2023 12:00:00 AM	8/17/2023 4:29 PM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	8/17/2023 4:29 PM
Details	Last Recertification Date	Update	Recertification	2/1/2022 8:56:58 AM	1/30/2023 2:27:19 PM	1/30/2023 2:27 PM
Details	Last Recertification Date	Update	Recertification	2/10/2021 8:19:57 AM	2/1/2022 8:56:58 AM	2/1/2022 8:56 AM
Contacts	Authorizing Official	Update	Profile Change Request	Marion, Dale Practice Manager Jane Pauley Community Health Center 3175520690	Marion, Dale 340B Program Manager Jane Pauley Community Health Center 3175520690	10/6/2021 7:51 AM
Contacts	Signed By	Update	Profile Change Request	Marion, Dale Practice Manager Jane Pauley Community Health Center 3175520690	Marion, Dale 340B Program Manager Jane Pauley Community Health Center 3175520690	10/6/2021 7:51 AM
Addresses	Billing Address	Insert	Recertification		Jane Pauley Community Health Center, Inc. 1503 N. Mitthoeffer Road Indianapolis, IN 46229	2/10/2021 8:19 AM
Contacts	Primary Contact	Update	Recertification	Boyle, Amanda Executive Administrator Jane Pauley Community Health Center 3179340755	Dale, Michael CFO Jane Pauley CHC 3179340751	2/10/2021 8:19 AM
Details	Last Recertification Date	Update	Recertification	1/27/2020 1:40:19 PM	2/10/2021 8:19:57 AM	2/10/2021 8:19 AM
Details	Last Recertification Date	Update	Recertification	1/29/2019 9:17:48 AM	1/27/2020 1:40:19 PM	1/27/2020 1:40 PM
Details	Last Recertification Date	Update	Recertification		1/29/2019 9:17:48 AM	1/29/2019 9:17 AM
Details	State	Update		Approved	Active	10/1/2018 12:05 AM
Contacts	Signed By	Insert	New Registration		Marion, Dale Practice Manager Jane Pauley Community Health Center 3175520690	8/24/2018 7:52 AM
Details	340B ID	Update	New Registration		CHC26566-19	8/24/2018 7:52 AM
Dates	Participating Approval Date	Update	New Registration		8/24/2018 7:52:56 AM	8/24/2018 7:52 AM
Details	State	Update	New Registration	Pending	Approved	8/24/2018 7:52 AM
Dates	Signed By Date	Update	New Registration		7/13/2018 4:36:13 PM	8/24/2018 7:52 AM
Dates	Start Date	Update	New Registration		10/1/2018 12:00:00 AM	8/24/2018 7:52 AM
Addresses	Main Address	Insert	New Registration		820 West Madison Avenue Zimmerman Hall Alexandria, IN 46001	7/13/2018 4:36 PM
Contacts	Primary Contact	Insert	New Registration		Boyle, Amanda Executive Administrator Jane Pauley Community Health Center 3179340755	7/13/2018 4:36 PM
Contacts	Authorizing Official	Insert	New Registration		Marion, Dale Practice Manager Jane Pauley Community Health Center 3175520690	7/13/2018 4:36 PM
Details	Last Recertification Date	Insert	New Registration			7/13/2018 4:36 PM
Details	Grant Number	Insert	New Registration		H80CS26566	7/13/2018 4:36 PM
Details	340B ID	Insert	New Registration			7/13/2018 4:36 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/13/2018 4:36 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/13/2018 4:36 PM
Details	Medicare Provider Number	Insert	New Registration			7/13/2018 4:36 PM
Details	Entity Name	Insert	New Registration		Jane Pauley Community Health Center, Inc.	7/13/2018 4:36 PM
Details	Program Code	Insert	New Registration		CH	7/13/2018 4:36 PM
Details	Entity Subname	Insert	New Registration		Jane Pauley Community Health Center at St. Mary School	7/13/2018 4:36 PM
Dates	Participating Approval Date	Insert	New Registration			7/13/2018 4:36 PM
Details	State	Insert	New Registration		Pending	7/13/2018 4:36 PM
Dates	Registration Date	Insert	New Registration		7/13/2018 4:36:11 PM	7/13/2018 4:36 PM
Dates	Signed By Date	Insert	New Registration			7/13/2018 4:36 PM
Dates	Start Date	Insert	New Registration			7/13/2018 4:36 PM
Terminations	Termination Comments	Insert	New Registration			7/13/2018 4:36 PM
Terminations	Termination Date	Insert	New Registration			7/13/2018 4:36 PM
Terminations	Termination Effective Date	Insert	New Registration			7/13/2018 4:36 PM
Terminations	Termination Reason	Insert	New Registration			7/13/2018 4:36 PM

340B Drug Pricing Program Database