Covered Entity Details

CH100790 LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC (Active) - information as of 6/17/2025 11:41:15 PM

Main Details

Name

LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC

Subdivision Name

PHOENIX HEALTH CENTER--LA CLINICA

Type

HRSA-Funded Health Center

Site ID

BPS-H80-001238

340B ID

CH100790

Grant Number

H80CS00759

Additional Details

Current Program Status

Active

Registration Date

1/1/1999

Participating Start Date

1/1/1999

Participating Approval Date

3/11/2004

Last Recertification Date

2/12/2025

Contacts

Authorizing Official

La Clinica del Valle
Traci Fossen, Chief Quality Officer
(541) 512-3912

Primary Contact

La Clinica del Valle
Sochil Castillo, Compliance Coordinator
(541) 512-3127

Addresses

Street Address

3617 S Pacific Hwy
Medford, OR 97501-8957

Billing Address

La Clinica Del Valle Family Health Care Center Inc
931 Chevy Way
Medford, OR 97504

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
History

Comments

Comment	Last Updated On
ENT NAME CORRECTION, NEW CONTACT	03/11/2004

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
OR	500769255,022868	1851327571,1023660099

Shipping Addresses

Shipping Address 1

La Clinica Del Valle Family Health Care Center Inc.
3617 S. Pacific Hwy
Medford, OR 97501

Shipping Address 2

La Clinica Del Valle Family Health Care Center Inc.
730 Biddle Road
Medford, OR 97504

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ALBERTSONS LLC	SAV-ON PHARMACY #3595	1360 PLAZA BLVD	CENTRAL POINT	OR	97502	10/05/2016	01/01/2017	01/04/2022	01/05/2022
Contract Detail	ALBERTSONS LLC	SAV-ON PHARMACY #3593	113 ROSS LANE	MEDFORD	OR	97501	10/05/2016	01/01/2017		10/05/2016
Contract Detail	ALBERTSONS LLC	SAV-ON PHARMACY #3508	910 N. PHOENIX RD	MEDFORD	OR	97504	10/05/2016	01/01/2017	01/04/2022	01/05/2022
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	07/10/2018	10/01/2018		10/01/2018
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	08/24/2022	08/29/2022		08/29/2022
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	08/24/2022	08/29/2022		08/29/2022
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	08/24/2022	08/29/2022		08/29/2022
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	08/24/2022	08/29/2022		08/29/2022
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	08/24/2022	08/29/2022		08/29/2022
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	08/24/2022	08/29/2022		08/29/2022
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	08/24/2022	08/29/2022		08/29/2022
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	08/24/2022	08/29/2022		08/29/2022
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	08/24/2022	08/29/2022		08/29/2022
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	08/24/2022	08/29/2022		08/29/2022
Contract Detail	CENTRAL DRUG INC	DBA BLACK OAK PHARMACY	2924 SISKIYOU BLVD STE 102	MEDFORD	OR	97504	10/11/2018	01/01/2019		01/01/2019
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	08/24/2022	08/29/2022		08/29/2022
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	08/24/2022	08/29/2022		08/29/2022
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	08/24/2022	08/29/2022		08/29/2022
Contract Detail	DOGWOOD PHARMACY, INC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER ROAD SUITE K	GREENVILLE	SC	29607-6540	07/10/2018	10/01/2018		10/01/2018
Contract Detail	MEDFORD PHARMACY GROUP, LLC	DBA: WEST MAIN PHARMACY	2355 W MAIN ST	MEDFORD	OR	97501	01/14/2020	04/01/2020		04/01/2020
Contract Detail	OREGON CVS PHARMACY, L.L.C.	CVS PHARMACY # 16159	2000 CRATER LAKE HWY	MEDFORD	OR	97504	07/15/2022	10/01/2022		10/01/2022
Contract Detail	PHOENIX DOWNTOWN PHARMACY, LLC		404 N. MAIN ST	PHOENIX	OR	97535-9632	12/06/2013	12/06/2013	10/10/2017	10/10/2017
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	08/24/2022	08/29/2022		08/29/2022
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	08/24/2022	08/29/2022		08/29/2022
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	08/24/2022	08/29/2022		08/29/2022
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	08/24/2022	08/29/2022		08/29/2022
Contract Detail	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	07/10/2018	10/01/2018		10/01/2018
Contract Detail	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	07/10/2018	10/01/2018		10/01/2018
Contract Detail	ROGUE PHARMACIES INC	DBA: CASCADE PHARMACY	7591A CRATER LAKE HWY	WHITE CITY	OR	97503-1663	03/07/2013	04/01/2013	02/05/2016	02/13/2018
Contract Detail	ROGUE PHARMACIES INC	DBA: CASCADE PHARMACY	7591A CRATER LAKE HWY	WHITE CITY	OR	97503-1663	01/07/2019	04/01/2019	08/08/2021	01/05/2022
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #0525	1003 MEDFORD SHOPPING CENTER	MEDFORD	OR	97504	04/15/2015	07/01/2015		09/22/2015
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1643	3169 CRATER LAKE HIWAY	MEDFORD	OR	97504	07/10/2018	10/01/2018	04/20/2019	07/12/2019
Contract Detail	WAL-MART PHARMACY 10-1834	135 NE TERRY LANE		GRANTS PASS	OR	97526	10/03/2018	01/01/2019		01/01/2019
Contract Detail	WAL-MART PHARMACY 10-2069	1360 CENTER DR.		MEDFORD	OR	97501	07/07/2015	10/01/2015		10/03/2018
Contract Detail	WAL-MART PHARMACY 10-5424	11500 HANNON ROAD		EAGLE POINT	OR	97524	10/03/2018	01/01/2019		01/01/2019
Contract Detail	WAL-MART PHARMACY 10-5839	3615 CRATER LAKE HWY		MEDFORD	OR	97504	10/03/2018	01/01/2019		01/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS #09328	210 E BARNETT RD.	MEDFORD	OR	97501-7928	10/15/2014	01/01/2015	05/02/2024	07/03/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12596	2280 W. MAIN ST.	MEDFORD	OR	97501	04/15/2015	07/01/2015		09/22/2015
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15974	43 N FRONT ST	CENTRAL POINT	OR	97502	04/15/2015	07/01/2015		09/22/2015
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #21151	1215 NW 23RD AVE	PORTLAND	OR	97210	04/07/2018	07/01/2018		04/07/2018
Contract Detail	WALGREENS MAIL SERVICE, INC.		8337 S PARK CIRCLE	ORLANDO	FL	32819-9049	10/15/2014	01/01/2015	07/10/2015	09/22/2015
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	10/15/2014	01/01/2015	07/10/2015	09/22/2015
Contract Detail	WEST MAIN DRUG, INC	DBA: WEST MAIN PHARMACY	2355 WEST MAIN	MEDFORD	OR	97501	01/27/2015	02/20/2015	11/01/2019	01/14/2020

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH100790	Active	BPS-H80-001238	LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC	PHOENIX HEALTH CENTER--LA CLINICA	3617 S Pacific Hwy	Medford	OR
CH10079AA	Active	BPS-H80-038597	La Clinica Del Valle Family Health Care Center, Inc.	La Clinica School Based Health Center at Armadillo Community Charter School	302 W 1st St	Phoenix	OR
CH10079AB	Active	BPS-H80-032024	La Clinica Del Valle Family Health Care Center, Inc.	La Clinica School-Based Health Center at Talent Elementary School	307 Wagner Creek Street RM 8 & 9	Talent	OR
CH10079AC	Active	BPS-H80-031978	La Clinica Del Valle Family Health Care Center, Inc.	La Clinica School-Based Health Center at Orchard Hill Elementary School	1011 La Loma Dr Rm 23	Medford	OR
CH10079AD	Terminated	BPS-H80-031822	La Clinica Del Valle Family Health Care Center, Inc.	La Clinica Acute Care Clinic	616 Market St	Medford	OR
CH10079AE	Active	BPS-H80-037036	LA CLINCA DEL VALLE FAMILY HEALTH CENTER INC	La Clinica School-Based Health Center at Rogue Primary School	600 S 2nd St	Central Point	OR
CH10079AF	Active	BPS-H80-036937	LA CLINCA DEL VALLE FAMILY HEALTH CENTER INC	La Clinica School-Based Health Center at Phoenix High School	745 N Rose St	Phoenix	OR
CH10079AG	Active	BPS-H80-037344	LA CLINCA DEL VALLE FAMILY HEALTH CENTER INC	La Clinica School-Based Health Center at Ashland High School	201 S. Mountain Avenue	ASHLAND	OR
CH10079AH	Active	BPS-H80-036993	LA CLINCA DEL VALLE FAMILY HEALTH CENTER INC	La Clinica at The OHRA Center	2350 Ashland St	Ashland	OR
CH10079AJ	Active	BPS-H80-027512	LA CLINCA DEL VALLE FAMILY HEALTH CENTER INC	Center for Learning and Innovation--La Clinica	931 Chevy Way	Medford	OR
CH10079AK	Active	BPS-H80-038877	LA CLINCA DEL VALLE FAMILY HEALTH CENTER INC	La Clinica Acute Care Clinic	638 Market St	Medford	OR
CH10079AL	Active	BPS-H80-038886	LA CLINCA DEL VALLE FAMILY HEALTH CENTER INC	La Clinica Student Health & Wellness Center at Southern Oregon University	560 Indiana St	Ashland	OR
CH10079C	Active	BPS-H80-003317	LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC	WEST MEDFORD HEALTH CENTER--La Clinica	1307 W Main St	Medford	OR
CH10079D	Active	BPS-H80024908	LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC	Women's Health Center--La Clinica	221 W Stewart Ave	Medford	OR
CH10079E	Active	BPS-H80-002801	LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC	CENTRAL POINT HEALTH CENTER--LA CLINICA	4940 Hamrick Rd	Central Point	OR
CH10079F	Active	BPS-H80-010141	LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC	East Medford Dental Clinic--La Clinica	1113 Progress Road	Medford	OR
CH10079G	Terminated	BPS-H80-011259	LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC	Mobile Health Center--La Clinica	3617 S Pacific Hwy	Medford	OR
CH10079H	Terminated	BPS-H80-004354	LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC	La Clinica School-Based Health Center at Jackson Elementary School	320 W 2nd St	Medford	OR
CH10079J	Active	BPS-H80-005004	LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC	La Clinica School-Based Health Center at Washington Elementary School	610 S PEACH ST	MEDFORD	OR
CH10079K	Active	BPS-H80-009576	LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC	La Clinica School-Based Health Center at Jewett Elementary School	1001 Manzanita St	Central Point	OR
CH10079L	Active	BPS-H80-000679	LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC	La Clinica School-Based Health Center at Oak Grove Elementary School	2838 W Main St	Medford	OR
CH10079M	Active	BPS-H80-000664	LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC	La Clinica School-Based Health Center at Phoenix Elementary School	215 N. ROSE STREET	PHOENIX	OR
CH10079N	Active	BPS-H80-012393	LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC	La Clinica School-Based Health Center at Crater High School	655 N 3rd St	Central Point	OR
CH10079P	Active	BPS-H80-008109	LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC	Birch Grove Health Center-La Clinica	910 S Central Ave	MEDFORD	OR
CH10079Q	Active	BPS-H80-013804	LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC	La Clinica School-Based Health Center at Scenic Middle School	1955 SCENIC AVE	CENTRAL POINT	OR
CH10079R	Active	BPS-H80-014459	LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC	La Clinica School Based Health Center at Mae Richardson Elementary School	200 W PINE ST	CENTRAL POINT	OR
CH10079S	Active	BPS-H80-014456	LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC	La Clinica School Based Health Center at Central Point Elementary School	450 S 4TH ST	CENTRAL POINT	OR
CH10079T	Active	BPS-H80-015516	LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC	La Clinica Wellness Center	730 BIDDLE RD	MEDFORD	OR
CH10079U	Active	BPS-H80-021670	La Clinica Del Valle Family Health Care Center Inc	La Clinica School-Based Health Center at Hanby Middle School	806 6th Ave N	Gold Hill	OR
CH10079V	Terminated	BPS-H80-024876	La Clinica Del Valle Family Health Care Center Inc	La Clinica School-Based Health Center at Kids Unlimited	821 N Riverside Ave	Medford	OR
CH10079W	Active	BPS-H80-027337	La Clinica Del Valle Family Health Care Center Inc	La Clinica School-Based Health Center at Patrick Elementary School	1500 2nd Avenue	Gold Hill	OR
CH10079X	Active	BPS-H80-027381	La Clinica Del Valle Family Health Care Center Inc	La Clinica School-Based Health Center at Sams Valley Elementary School	14235 Table Rock Rd	Central Point	OR
CH10079Y	Active	BPS-H80-031864	La Clinica Del Valle Family Health Care Center, Inc.	La Clinica School-Based Health Center at Talent Middle School	102 Christian Ave	Talent	OR
CH10079Z	Active	BPS-H80-031647	La Clinica Del Valle Family Health Care Center, Inc.	La Clinica School-Based Health Center at Jackson Elementary School	713 Summit Ave	Medford	OR

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH100790	ALBERTSONS LLC	SAV-ON PHARMACY #3595	1360 PLAZA BLVD	CENTRAL POINT	OR	97502	01/01/2017	01/04/2022
CH100790	ALBERTSONS LLC	SAV-ON PHARMACY #3593	113 ROSS LANE	MEDFORD	OR	97501	01/01/2017
CH100790	ALBERTSONS LLC	SAV-ON PHARMACY #3508	910 N. PHOENIX RD	MEDFORD	OR	97504	01/01/2017	01/04/2022
CH10079AC	ALBERTSONS LLC	SAV-ON PHARMACY #3593	113 ROSS LANE	MEDFORD	OR	97501	04/01/2024
CH100790	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	10/01/2018
CH100790	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	08/29/2022
CH100790	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	08/29/2022
CH100790	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	08/29/2022
CH100790	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	08/29/2022
CH100790	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	08/29/2022
CH100790	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	08/29/2022
CH100790	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	08/29/2022
CH100790	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	08/29/2022
CH100790	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	08/29/2022
CH100790	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	08/29/2022
CH100790	CENTRAL DRUG INC	DBA BLACK OAK PHARMACY	2924 SISKIYOU BLVD STE 102	MEDFORD	OR	97504	01/01/2019
CH100790	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	08/29/2022
CH100790	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	08/29/2022
CH100790	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	08/29/2022
CH100790	DOGWOOD PHARMACY, INC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER ROAD SUITE K	GREENVILLE	SC	29607-6540	10/01/2018
CH100790	MEDFORD PHARMACY GROUP, LLC	DBA: WEST MAIN PHARMACY	2355 W MAIN ST	MEDFORD	OR	97501	04/01/2020
CH10079AF	MEDFORD PHARMACY GROUP, LLC	DBA: WEST MAIN PHARMACY	2355 W MAIN ST	MEDFORD	OR	97501	04/01/2024
CH100790	OREGON CVS PHARMACY, L.L.C.	CVS PHARMACY # 16159	2000 CRATER LAKE HWY	MEDFORD	OR	97504	10/01/2022
CH10079C	OREGON CVS PHARMACY, L.L.C.	CVS PHARMACY # 16159	2000 CRATER LAKE HWY	MEDFORD	OR	97504	04/01/2024
CH100790	PHOENIX DOWNTOWN PHARMACY, LLC		404 N. MAIN ST	PHOENIX	OR	97535-9632	12/06/2013	10/10/2017
CH100790	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	08/29/2022
CH100790	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	08/29/2022
CH100790	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	08/29/2022
CH100790	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	08/29/2022
CH100790	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	10/01/2018
CH100790	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	10/01/2018
CH100790	ROGUE PHARMACIES INC	DBA: CASCADE PHARMACY	7591A CRATER LAKE HWY	WHITE CITY	OR	97503-1663	04/01/2013	02/05/2016
CH10079E	ROGUE PHARMACIES INC	DBA: CASCADE PHARMACY	7591A CRATER LAKE HWY	WHITE CITY	OR	97503-1663	08/06/2009	02/05/2016
CH100790	ROGUE PHARMACIES INC	DBA: CASCADE PHARMACY	7591A CRATER LAKE HWY	WHITE CITY	OR	97503-1663	04/01/2019	08/08/2021
CH100790	SAFEWAY INC	SAFEWAY PHARMACY #0525	1003 MEDFORD SHOPPING CENTER	MEDFORD	OR	97504	07/01/2015
CH100790	SAFEWAY INC	SAFEWAY PHARMACY #1643	3169 CRATER LAKE HIWAY	MEDFORD	OR	97504	10/01/2018	04/20/2019
CH100790	WAL-MART PHARMACY 10-1834	135 NE TERRY LANE		GRANTS PASS	OR	97526	01/01/2019
CH100790	WAL-MART PHARMACY 10-2069	1360 CENTER DR.		MEDFORD	OR	97501	10/01/2015
CH10079AB	WAL-MART PHARMACY 10-2069	1360 CENTER DR.		MEDFORD	OR	97501	04/01/2024
CH100790	WAL-MART PHARMACY 10-5424	11500 HANNON ROAD		EAGLE POINT	OR	97524	01/01/2019
CH10079AE	WAL-MART PHARMACY 10-5424	11500 HANNON ROAD		EAGLE POINT	OR	97524	04/01/2024
CH100790	WAL-MART PHARMACY 10-5839	3615 CRATER LAKE HWY		MEDFORD	OR	97504	01/01/2019
CH10079AD	WAL-MART PHARMACY 10-5839	3615 CRATER LAKE HWY		MEDFORD	OR	97504	04/01/2024	01/01/2025
CH100790	WALGREEN CO.	DBA: WALGREENS #09328	210 E BARNETT RD.	MEDFORD	OR	97501-7928	01/01/2015	05/02/2024
CH100790	WALGREEN CO.	DBA: WALGREENS #12596	2280 W. MAIN ST.	MEDFORD	OR	97501	07/01/2015
CH100790	WALGREEN CO.	DBA: WALGREENS #15974	43 N FRONT ST	CENTRAL POINT	OR	97502	07/01/2015
CH100790	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #21151	1215 NW 23RD AVE	PORTLAND	OR	97210	07/01/2018
CH10079C	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #21151	1215 NW 23RD AVE	PORTLAND	OR	97210	07/01/2018
CH10079E	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #21151	1215 NW 23RD AVE	PORTLAND	OR	97210	07/01/2018
CH10079AA	WALGREEN CO.	DBA: WALGREENS #09328	210 E BARNETT RD.	MEDFORD	OR	97501-7928	04/01/2024
CH100790	WALGREENS MAIL SERVICE, INC.		8337 S PARK CIRCLE	ORLANDO	FL	32819-9049	01/01/2015	07/10/2015
CH100790	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	01/01/2015	07/10/2015
CH100790	WEST MAIN DRUG, INC	DBA: WEST MAIN PHARMACY	2355 WEST MAIN	MEDFORD	OR	97501	02/20/2015	11/01/2019

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	1/30/2024 1:19:45 PM	2/12/2025 10:06:49 AM	2/12/2025 10:06 AM
Details	Last Recertification Date	Update	Recertification	2/3/2023 3:34:28 PM	1/30/2024 1:19:45 PM	1/30/2024 1:19 PM
Details	Last Recertification Date	Update	Recertification	2/15/2022 3:55:45 PM	2/3/2023 3:34:28 PM	2/3/2023 3:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/22/2022 1:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		500769255	7/22/2022 1:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	7/22/2022 1:22 PM
Addresses	Shipping Address	Insert	Group Change Request		La Clinica Del Valle Family Health Care Center Inc. 3617 S. Pacific Hwy Medford, OR 97501	7/21/2022 12:02 PM
Addresses	Shipping Address	Insert	Group Change Request		La Clinica Del Valle Family Health Care Center Inc. 730 Biddle Road Medford, OR 97504	7/21/2022 12:02 PM
Addresses	Shipping Address	Delete	Group Change Request	La Clinica Community Pharmacy 3617 S. Pacific Hwy. Medford, OR 97501		7/15/2022 9:55 AM
Addresses	Shipping Address	Delete	Group Change Request	La Clinica Del Valle Family Health Care Center Inc 730 Biddle Road Medford, OR 97504-6116		7/15/2022 9:55 AM
Details	Last Recertification Date	Update	Recertification	2/5/2021 6:35:15 PM	2/15/2022 3:55:45 PM	2/15/2022 3:55 PM
Medicaid Billing	NPI: State	Update	Recertification		OR	2/5/2021 6:35 PM
Details	Last Recertification Date	Update	Recertification	2/7/2020 11:01:55 AM	2/5/2021 6:35:15 PM	2/5/2021 6:35 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1023660099	10/27/2020 11:22 AM
Medicaid Billing	NPI: State	Insert	Change Request		OR	10/27/2020 11:22 AM
Addresses	Shipping Address	Insert	Change Request		La Clinica Del Valle Family Health Care Center Inc 730 Biddle Road Medford, OR 97504-6116	10/23/2020 8:57 AM
Details	Last Recertification Date	Update	Recertification	2/20/2019 4:38:08 PM	2/7/2020 11:01:55 AM	2/7/2020 11:01 AM
Addresses	Shipping Address	Insert	Change Request		La Clinica Community Pharmacy 3617 S. Pacific Hwy. Medford, OR 97501	8/22/2019 8:34 AM
Addresses	Billing Address	Insert	Change Request		La Clinica Del Valle Family Health Care Center Inc 931 Chevy Way Medford, OR 97504	7/10/2019 2:43 PM
Details	Entity Subname	Update	Change Request	PHOENIX HEALTH CENTER--LA CLINICA DEL VALLE	PHOENIX HEALTH CENTER--LA CLINICA	7/10/2019 2:43 PM
Details	Last Recertification Date	Update	Recertification	2/13/2018 8:06:42 PM	2/20/2019 4:38:08 PM	2/20/2019 4:38 PM
Details	Last Recertification Date	Update	Recertification	2/3/2017 12:00:00 AM	2/13/2018 8:06:42 PM	2/13/2018 8:06 PM
Contacts	Primary Contact	Update	Profile Change Request	Castiloo, Sochil Compliance Coordinator La Clinica del Valle 5415123127	Castillo, Sochil Compliance Coordinator La Clinica del Valle 5415123127	10/10/2017 7:23 PM
Contacts	Primary Contact	Update		Castillo, Sochil Compliance Coordinator La Clinica del Valle 5415123127	Castiloo, Sochil Compliance Coordinator La Clinica del Valle 5415123127	10/10/2017 7:19 PM
Contacts	Primary Contact	Update	Change Request	Castiloo, Sochil Compliance Coordinator La Clinica del Valle 5415123127	Castillo, Sochil Compliance Coordinator La Clinica del Valle 5415123127	10/10/2017 7:18 PM
Contacts	Primary Contact	Update	Change Request	Kirk, Tara Performance Excellence Director 5416903538	Castiloo, Sochil Compliance Coordinator La Clinica del Valle 5415123127	10/10/2017 6:53 PM
Contacts	Authorizing Official	Update		Fossen, Traci Chief Quality Officer 5415123912	Fossen, Traci Chief Quality Officer La Clinica del Valle 5415123912	10/10/2017 4:57 PM
Addresses	Main Address	Insert			3617 S Pacific Hwy Medford, OR 97501-8957	4/7/2017 7:04 PM
Contacts	Primary Contact	Update		Gauger, Toni Risk & Compliance Coordinator 5416903547	Kirk, Tara Performance Excellence Director 5416903538	4/7/2017 7:04 PM
Contacts	Authorizing Official	Insert			Fossen, Traci Chief Quality Officer 5415123912	4/7/2017 7:04 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/7/2017 7:04 PM
Medicaid Billing	Medicaid: Number	Insert			022868	4/7/2017 7:04 PM
Medicaid Billing	Medicaid: State	Insert			OR	4/7/2017 7:04 PM
Medicaid Billing	NPI: Number	Insert			1851327571	4/7/2017 7:04 PM
Details	Last Recertification Date	Update		2/23/2016 12:00:00 AM	2/3/2017 12:00:00 AM	2/3/2017 4:54 PM
Contacts	Primary Contact	Update		RUPPE, ANGELICA CFO 5415123150	Gauger, Toni Risk & Compliance Coordinator 5416903547	2/23/2016 4:50 PM
Details	Last Recertification Date	Update		3/4/2015 12:00:00 AM	2/23/2016 12:00:00 AM	2/23/2016 4:50 PM
Contacts	Primary Contact	Insert			RUPPE, ANGELICA CFO 5415123150	9/22/2015 4:31 PM
Dates	Participating Approval Date	Update		3/11/2004 11:55:18 AM	3/11/2004 12:00:00 AM	4/6/2015 4:41 PM
Details	Last Recertification Date	Update		2/12/2014 12:00:00 AM	3/4/2015 12:00:00 AM	3/4/2015 2:07 PM
Details	Entity Name	Update		LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER	LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC	3/31/2014 4:25 PM
Details	Entity Subname	Update			PHOENIX HEALTH CENTER--LA CLINICA DEL VALLE	3/31/2014 4:25 PM
Details	Last Recertification Date	Update		4/1/2013 12:00:00 AM	2/12/2014 12:00:00 AM	2/12/2014 4:50 PM
Details	Last Recertification Date	Update			4/1/2013 12:00:00 AM	3/4/2013 8:21 AM
Details	Last Recertification Date	Insert				3/11/2004 11:55 AM
Details	Grant Number	Insert			H80CS00759	3/11/2004 11:55 AM
Details	340B ID	Insert			CH100790	3/11/2004 11:55 AM
Details	Is Authorizing Official EHB Data	Insert				3/11/2004 11:55 AM
Dates	Last Date That 340B Drugs Purchased	Insert				3/11/2004 11:55 AM
Details	Medicare Provider Number	Insert				3/11/2004 11:55 AM
Details	Entity Name	Insert			LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER	3/11/2004 11:55 AM
Details	Program Code	Insert			CH	3/11/2004 11:55 AM
Details	Entity Subname	Insert				3/11/2004 11:55 AM
Dates	Participating Approval Date	Insert			3/11/2004 11:55:18 AM	3/11/2004 11:55 AM
Details	State	Insert			Active	3/11/2004 11:55 AM
Dates	Registration Date	Insert			1/1/1999 12:00:00 AM	3/11/2004 11:55 AM
Dates	Signed By Date	Insert				3/11/2004 11:55 AM
Dates	Start Date	Insert			1/1/1999 12:00:00 AM	3/11/2004 11:55 AM
Terminations	Termination Comments	Insert				3/11/2004 11:55 AM
Terminations	Termination Date	Insert				3/11/2004 11:55 AM
Terminations	Termination Effective Date	Insert				3/11/2004 11:55 AM
Terminations	Termination Reason	Insert				3/11/2004 11:55 AM
Details	Comments Public	Insert			ENT NAME CORRECTION, NEW CONTACT	3/11/2004 11:55 AM

340B Drug Pricing Program Database