Covered Entity Details

CHC28992-04 Sac Health System (Active) - information as of 4/25/2025 5:40:35 PM

Main Details

Name

Sac Health System

Subdivision Name

SAC Health System Indio Clinic

Type

HRSA-Funded Health Center

Site ID

BPS-H80-021921

340B ID

CHC28992-04

Grant Number

H80CS28992

Additional Details

Current Program Status

Active

Registration Date

12/5/2018

Participating Start Date

1/1/2019

Participating Approval Date

12/10/2018

Last Recertification Date

2/11/2025

Contacts

Authorizing Official

SACHS
bonnie inquinn chi-lum, CMO
(951) 235-0642

Primary Contact

SAC Health
Tasha Amick, Director of Billing
(909) 219-8665 Ext: 4230

Addresses

Street Address

82-934 Civic Center Drive
Indio, CA 92201-4308

Billing Address
Same as Street Address

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		1831624493

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	LOMA LINDA UNIVERSITY PHARMACY	250 S G ST		SAN BERNARDINO	CA	92410	04/07/2020	07/01/2020	04/17/2022	11/13/2023
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5693	2025 EAST WASHINGTON STREET	COLTON	CA	92324	07/08/2019	10/01/2019	11/06/2023	11/13/2023
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5694	1133 N.MOUNT VERNON AVE.	COLTON	CA	92324	07/08/2019	10/01/2019	11/06/2023	11/13/2023
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #6256	25710 BARTON ROAD	LOMA LINDA	CA	92354	07/08/2019	10/01/2019	11/06/2023	11/13/2023
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5710	2130 EAST HIGHLAND AVENUE	SAN BERNARDINO	CA	92404	07/08/2019	10/01/2019	11/06/2023	11/13/2023
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5671	1660 E FIRST ST	BEAUMONT	CA	92223-3715	07/08/2019	10/01/2019	11/06/2023	11/13/2023
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5692	27177 HIGHWAY 189 SUITE E PO BOX 3338	BLUE JAY	CA	92317	07/08/2019	10/01/2019	11/06/2023	11/13/2023
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/17/2019	07/01/2019	11/28/2023	11/28/2023
Contract Detail	WAL-MART PHARMACY 10-1692	1120 SOUTH MT VERNON AVE		COLTON	CA	92324	04/17/2019	07/01/2019	11/28/2023	11/28/2023
Contract Detail	WAL-MART PHARMACY 10-1693	2050 W REDLANDS BLVD		REDLANDS	CA	92374	04/17/2019	07/01/2019	11/28/2023	11/28/2023
Contract Detail	WAL-MART PHARMACY 10-1914	4210 EAST HIGHLAND AVE		HIGHLAND	CA	92346	04/17/2019	07/01/2019	11/28/2023	11/28/2023
Contract Detail	WAL-MART PHARMACY 10-3276	4001 HALLMARK PKWY		SAN BERNARDINO (N)	CA	92407	04/17/2019	07/01/2019	11/28/2023	11/28/2023
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/17/2019	07/01/2019	11/28/2023	11/28/2023
Contract Detail	WALMART PHARMACY 10-2998	25755 BARTON RD		LOMA LINDA	CA	92354	04/17/2019	07/01/2019	11/28/2023	11/28/2023

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CHC28992-00	Active	BPS-H80-015547	SAC HEALTH SYSTEM	SACHS-Norton Clinic	1455 E 3rd St	San Bernardino	CA
CHC28992-01	Terminated	BPS-H80-015538	SAC HEALTH SYSTEM	SACHS-Arrowhead Clinic	1293 N D St	San Bernardino	CA
CHC28992-02	Active	BPS-H80-018401	SAC HEALTH SYSTEM	SAC Health System Downtown Clinic	250 S. G Street	San Bernardino	CA
CHC28992-03	Active	BPS-H80-015539	Sac Health System	SACHS-Frazee Clinic	488 S K St	San Bernardino	CA
CHC28992-04	Active	BPS-H80-021921	Sac Health System	SAC Health System Indio Clinic	82-934 Civic Center Drive	Indio	CA
CHC28992-05	Active	BPS-H80-030646	Sac Health System	SAC Indio CVRM Manila	84110 Manila Ave # B	Indio	CA
CHC28992-06	Terminated	BPS-H80-028034	Sac Health System	SAC Health System SBCUSD School-Based Clinic	781 W 2nd St Ste C	San Bernardino	CA
CHC28992-07	Active	BPS-H80-030645	Sac Health System	SAC Indio CVRM	47470 Van Buren St	Indio	CA
CHC28992-08	Terminated	BPS-H80-030648	Sac Health System	SAC Mobile Unit #1	250 S G St	San Bernardino	CA
CHC28992-09	Active	BPS-H80-030921	Sac Health System	SAC Rialto USD	815 S Willow Ave	Rialto	CA
CHC28992-10	Active	BPS-H80-031730	Sac Health System	SAC Murrieta	28078 Baxter Rd Ste 540	Murrieta	CA
CHC28992-11	Active	BPS-H80-034011	Sac Health System	SAC Blythe Medical	332 W Hobsonway	Blythe	CA
CHC28992-12	Terminated	BPS-H80-033961	Sac Health System	SAC Barstow	801 E Mountain View St	Barstow	CA
CHC28992-13	Active	BPS-H80-034012	Sac Health System	SAC Blythe Medical and Behavioral Health	322 W Hobsonway	Blythe	CA
CHC28992-14	Active	BPS-H80-034915	SAC HEALTH SYSTEM	SAC Murrieta Suite 128	28078 Baxter Rd STE 128	Murrieta	CA
CHC28992-15	Active	BPS-H80-037730	SAC HEALTH SYSTEM	SAC Mobile Unit #3	250 S G St	San Bernardino	CA
CHC28992-16	Active	BPS-H80-038535	SAC HEALTH SYSTEM	SAC Barstow Suite 101	801 E Mountain View St Suite 101	Barstow	CA
CHC28992-17	Active	BPS-H80-038534	SAC HEALTH SYSTEM	SAC Barstow Suite 102	801 E Mountain View St Suite 102	Barstow	CA
CHC28992-18	Approved	BPS-H80-039314	SAC HEALTH SYSTEM	SAC Murrieta Suite 430	28078 Baxter Rd, Ste 430	Murrieta	CA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CHC28992-02	LOMA LINDA UNIVERSITY PHARMACY	250 S G ST		SAN BERNARDINO	CA	92410	07/01/2020	04/17/2022
CHC28992-04	LOMA LINDA UNIVERSITY PHARMACY	250 S G ST		SAN BERNARDINO	CA	92410	07/01/2020	04/17/2022
CHC28992-00	LOMA LINDA UNIVERSITY PHARMACY	250 S G ST		SAN BERNARDINO	CA	92410	07/01/2020	04/17/2022
CHC28992-03	LOMA LINDA UNIVERSITY PHARMACY	250 S G ST		SAN BERNARDINO	CA	92410	07/01/2020	04/17/2022
CHC28992-02	THRIFTY PAYLESS, INC.	RITE AID #5671	1660 E FIRST ST	BEAUMONT	CA	92223-3715	10/01/2019	11/06/2023
CHC28992-04	THRIFTY PAYLESS, INC.	RITE AID #5693	2025 EAST WASHINGTON STREET	COLTON	CA	92324	10/01/2019	11/06/2023
CHC28992-02	THRIFTY PAYLESS, INC.	RITE AID #5710	2130 EAST HIGHLAND AVENUE	SAN BERNARDINO	CA	92404	10/01/2019	11/06/2023
CHC28992-00	THRIFTY PAYLESS, INC.	RITE AID #5693	2025 EAST WASHINGTON STREET	COLTON	CA	92324	10/01/2019	11/06/2023
CHC28992-00	THRIFTY PAYLESS, INC.	RITE AID #5694	1133 N.MOUNT VERNON AVE.	COLTON	CA	92324	10/01/2019	11/06/2023
CHC28992-03	THRIFTY PAYLESS, INC.	RITE AID #5710	2130 EAST HIGHLAND AVENUE	SAN BERNARDINO	CA	92404	10/01/2019	11/06/2023
CHC28992-04	THRIFTY PAYLESS, INC.	RITE AID #5694	1133 N.MOUNT VERNON AVE.	COLTON	CA	92324	10/01/2019	11/06/2023
CHC28992-03	THRIFTY PAYLESS, INC.	RITE AID #5671	1660 E FIRST ST	BEAUMONT	CA	92223-3715	10/01/2019	11/06/2023
CHC28992-04	THRIFTY PAYLESS, INC.	RITE AID #6256	25710 BARTON ROAD	LOMA LINDA	CA	92354	10/01/2019	11/06/2023
CHC28992-03	THRIFTY PAYLESS, INC.	RITE AID #5693	2025 EAST WASHINGTON STREET	COLTON	CA	92324	10/01/2019	11/06/2023
CHC28992-00	THRIFTY PAYLESS, INC.	RITE AID #5671	1660 E FIRST ST	BEAUMONT	CA	92223-3715	10/01/2019	11/06/2023
CHC28992-02	THRIFTY PAYLESS, INC.	RITE AID #5694	1133 N.MOUNT VERNON AVE.	COLTON	CA	92324	10/01/2019	11/06/2023
CHC28992-00	THRIFTY PAYLESS, INC.	RITE AID #5692	27177 HIGHWAY 189 SUITE E PO BOX 3338	BLUE JAY	CA	92317	10/01/2019	11/06/2023
CHC28992-03	THRIFTY PAYLESS, INC.	RITE AID #5694	1133 N.MOUNT VERNON AVE.	COLTON	CA	92324	10/01/2019	11/06/2023
CHC28992-02	THRIFTY PAYLESS, INC.	RITE AID #6256	25710 BARTON ROAD	LOMA LINDA	CA	92354	10/01/2019	11/06/2023
CHC28992-02	THRIFTY PAYLESS, INC.	RITE AID #5693	2025 EAST WASHINGTON STREET	COLTON	CA	92324	10/01/2019	11/06/2023
CHC28992-00	THRIFTY PAYLESS, INC.	RITE AID #6256	25710 BARTON ROAD	LOMA LINDA	CA	92354	10/01/2019	11/06/2023
CHC28992-04	THRIFTY PAYLESS, INC.	RITE AID #5710	2130 EAST HIGHLAND AVENUE	SAN BERNARDINO	CA	92404	10/01/2019	11/06/2023
CHC28992-04	THRIFTY PAYLESS, INC.	RITE AID #5671	1660 E FIRST ST	BEAUMONT	CA	92223-3715	10/01/2019	11/06/2023
CHC28992-00	THRIFTY PAYLESS, INC.	RITE AID #5710	2130 EAST HIGHLAND AVENUE	SAN BERNARDINO	CA	92404	10/01/2019	11/06/2023
CHC28992-03	THRIFTY PAYLESS, INC.	RITE AID #6256	25710 BARTON ROAD	LOMA LINDA	CA	92354	10/01/2019	11/06/2023
CHC28992-03	THRIFTY PAYLESS, INC.	RITE AID #5692	27177 HIGHWAY 189 SUITE E PO BOX 3338	BLUE JAY	CA	92317	10/01/2019	11/06/2023
CHC28992-02	THRIFTY PAYLESS, INC.	RITE AID #5692	27177 HIGHWAY 189 SUITE E PO BOX 3338	BLUE JAY	CA	92317	10/01/2019	11/06/2023
CHC28992-04	THRIFTY PAYLESS, INC.	RITE AID #5692	27177 HIGHWAY 189 SUITE E PO BOX 3338	BLUE JAY	CA	92317	10/01/2019	11/06/2023
CHC28992-00	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/01/2019	11/28/2023
CHC28992-04	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/01/2019	11/28/2023
CHC28992-03	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/01/2019	11/28/2023
CHC28992-02	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/01/2019	11/28/2023
CHC28992-02	WAL-MART PHARMACY 10-1692	1120 SOUTH MT VERNON AVE		COLTON	CA	92324	07/01/2019	11/28/2023
CHC28992-04	WAL-MART PHARMACY 10-1692	1120 SOUTH MT VERNON AVE		COLTON	CA	92324	07/01/2019	11/28/2023
CHC28992-03	WAL-MART PHARMACY 10-1692	1120 SOUTH MT VERNON AVE		COLTON	CA	92324	07/01/2019	11/28/2023
CHC28992-00	WAL-MART PHARMACY 10-1692	1120 SOUTH MT VERNON AVE		COLTON	CA	92324	07/01/2019	11/28/2023
CHC28992-02	WAL-MART PHARMACY 10-1693	2050 W REDLANDS BLVD		REDLANDS	CA	92374	07/01/2019	11/28/2023
CHC28992-04	WAL-MART PHARMACY 10-1693	2050 W REDLANDS BLVD		REDLANDS	CA	92374	07/01/2019	11/28/2023
CHC28992-00	WAL-MART PHARMACY 10-1693	2050 W REDLANDS BLVD		REDLANDS	CA	92374	07/01/2019	11/28/2023
CHC28992-03	WAL-MART PHARMACY 10-1693	2050 W REDLANDS BLVD		REDLANDS	CA	92374	07/01/2019	11/28/2023
CHC28992-00	WAL-MART PHARMACY 10-1914	4210 EAST HIGHLAND AVE		HIGHLAND	CA	92346	07/01/2019	11/28/2023
CHC28992-02	WAL-MART PHARMACY 10-1914	4210 EAST HIGHLAND AVE		HIGHLAND	CA	92346	07/01/2019	11/28/2023
CHC28992-04	WAL-MART PHARMACY 10-1914	4210 EAST HIGHLAND AVE		HIGHLAND	CA	92346	07/01/2019	11/28/2023
CHC28992-03	WAL-MART PHARMACY 10-1914	4210 EAST HIGHLAND AVE		HIGHLAND	CA	92346	07/01/2019	11/28/2023
CHC28992-04	WAL-MART PHARMACY 10-3276	4001 HALLMARK PKWY		SAN BERNARDINO (N)	CA	92407	07/01/2019	11/28/2023
CHC28992-03	WAL-MART PHARMACY 10-3276	4001 HALLMARK PKWY		SAN BERNARDINO (N)	CA	92407	07/01/2019	11/28/2023
CHC28992-02	WAL-MART PHARMACY 10-3276	4001 HALLMARK PKWY		SAN BERNARDINO (N)	CA	92407	07/01/2019	11/28/2023
CHC28992-00	WAL-MART PHARMACY 10-3276	4001 HALLMARK PKWY		SAN BERNARDINO (N)	CA	92407	07/01/2019	11/28/2023
CHC28992-04	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/01/2019	11/28/2023
CHC28992-03	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/01/2019	11/28/2023
CHC28992-02	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/01/2019	11/28/2023
CHC28992-00	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/01/2019	11/28/2023
CHC28992-00	WALMART PHARMACY 10-2998	25755 BARTON RD		LOMA LINDA	CA	92354	07/01/2019	11/28/2023
CHC28992-02	WALMART PHARMACY 10-2998	25755 BARTON RD		LOMA LINDA	CA	92354	07/01/2019	11/28/2023
CHC28992-03	WALMART PHARMACY 10-2998	25755 BARTON RD		LOMA LINDA	CA	92354	07/01/2019	11/28/2023
CHC28992-04	WALMART PHARMACY 10-2998	25755 BARTON RD		LOMA LINDA	CA	92354	07/01/2019	11/28/2023

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	1/30/2024 2:42:56 PM	2/11/2025 1:24:44 PM	2/11/2025 1:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	CMM70744F (CA)		2/7/2024 7:57 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801270137 (CA)		2/7/2024 7:57 PM
Details	Last Recertification Date	Update	Recertification	1/30/2023 3:28:39 PM	1/30/2024 2:42:56 PM	1/30/2024 2:42 PM
Details	Last Recertification Date	Update	Recertification	1/31/2022 12:55:09 PM	1/30/2023 3:28:39 PM	1/30/2023 3:28 PM
Details	Last Recertification Date	Update	Recertification	2/2/2021 6:15:29 PM	1/31/2022 12:55:09 PM	1/31/2022 12:55 PM
Contacts	Primary Contact	Update	Change Request	Amick, Tasha Director of Billing SACHS 9093827180-37272	Amick, Tasha Director of Billing SAC Health 9092198665-4230	1/4/2022 10:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/2/2021 6:15 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		CMM70744F	2/2/2021 6:15 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	2/2/2021 6:15 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	2/2/2021 6:15 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	2/2/2021 6:15 PM
Details	Last Recertification Date	Update	Recertification	1/27/2020 6:00:11 PM	2/2/2021 6:15:29 PM	2/2/2021 6:15 PM
Details	Last Recertification Date	Update	Recertification	1/29/2019 9:00:24 PM	1/27/2020 6:00:11 PM	1/27/2020 6:00 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1801270137	6/6/2019 4:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1831624493	2/6/2019 7:38 PM
Details	Last Recertification Date	Update	Recertification		1/29/2019 9:00:24 PM	1/29/2019 9:00 PM
Details	State	Update		Approved	Active	1/1/2019 12:05 AM
Contacts	Signed By	Insert	New Registration		chi-lum, bonnie inquinn CMO SACHS 9512350642	12/10/2018 9:00 AM
Details	340B ID	Update	New Registration		CHC28992-04	12/10/2018 9:00 AM
Dates	Participating Approval Date	Update	New Registration		12/10/2018 9:00:06 AM	12/10/2018 9:00 AM
Details	State	Update	New Registration	Pending	Approved	12/10/2018 9:00 AM
Dates	Signed By Date	Update	New Registration		12/5/2018 11:53:50 AM	12/10/2018 9:00 AM
Dates	Start Date	Update	New Registration		1/1/2019 12:00:00 AM	12/10/2018 9:00 AM
Addresses	Main Address	Insert	New Registration		82-934 Civic Center Drive Indio, CA 92201-4308	12/5/2018 11:53 AM
Contacts	Authorizing Official	Insert	New Registration		chi-lum, bonnie inquinn CMO SACHS 9512350642	12/5/2018 11:53 AM
Contacts	Primary Contact	Insert	New Registration		Amick, Tasha Director of Billing SACHS 9093827180-37272	12/5/2018 11:53 AM
Details	Last Recertification Date	Insert	New Registration			12/5/2018 11:53 AM
Details	Grant Number	Insert	New Registration		H80CS28992	12/5/2018 11:53 AM
Details	340B ID	Insert	New Registration			12/5/2018 11:53 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			12/5/2018 11:53 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			12/5/2018 11:53 AM
Details	Medicare Provider Number	Insert	New Registration			12/5/2018 11:53 AM
Details	Entity Name	Insert	New Registration		Sac Health System	12/5/2018 11:53 AM
Details	Program Code	Insert	New Registration		CH	12/5/2018 11:53 AM
Details	Entity Subname	Insert	New Registration		SAC Health System Indio Clinic	12/5/2018 11:53 AM
Dates	Participating Approval Date	Insert	New Registration			12/5/2018 11:53 AM
Details	State	Insert	New Registration		Pending	12/5/2018 11:53 AM
Dates	Registration Date	Insert	New Registration		12/5/2018 11:53:47 AM	12/5/2018 11:53 AM
Dates	Signed By Date	Insert	New Registration			12/5/2018 11:53 AM
Dates	Start Date	Insert	New Registration			12/5/2018 11:53 AM
Terminations	Termination Comments	Insert	New Registration			12/5/2018 11:53 AM
Terminations	Termination Date	Insert	New Registration			12/5/2018 11:53 AM
Terminations	Termination Effective Date	Insert	New Registration			12/5/2018 11:53 AM
Terminations	Termination Reason	Insert	New Registration			12/5/2018 11:53 AM

340B Drug Pricing Program Database