Covered Entity Details

FQHCLA81T NORTHEAST COMMUNITY CLINIC, INC (Active) - information as of 5/26/2025 12:56:00 AM

Main Details

Name

NORTHEAST COMMUNITY CLINIC, INC

Subdivision Name

Northeast Community Clinic

Type

Health Center Program Look-Alike

Site ID

BPS-LAL-024835

340B ID

FQHCLA81T

Grant Number

LALCS00033

Additional Details

Current Program Status

Active

Registration Date

7/2/2019

Participating Start Date

10/1/2019

Participating Approval Date

8/5/2019

Last Recertification Date

3/4/2025

Contacts

Authorizing Official

Northeast Community Clinic
CHRISTOPHER LAU, EXECUTIVE DIRECTOR
(626) 457-6900

Primary Contact

Northeast Community Clinic
Emely Orozco, Pharmacy Program Administrator
(626) 457-5209

Addresses

Street Address

4455 W 117th St Ste 502
Hawthorne, CA 90250-2261

Billing Address

Northeast Community Clinic
2550 West Main Street
301
Alhambra, CA 91801

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	1124460274	1124460274

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
FQHCLA81	Terminated	ADMIN ONLY	NORTHEAST COMMUNITY CLINIC		2550 W MAIN STREET, SUITE 301	ALHAMBRA	CA
FQHCLA81B	Active	BPS-LAL-009874	NORTHEAST COMMUNITY CLINIC, INC	Northeast Community Clinic - Community Medical Alliance	4129 E Gage Ave	Bell	CA
FQHCLA81C	Terminated	BPS-LAL-012825	NORTHEAST COMMUNITY CLINIC	NECC - GAGE HEALTH CENTER	2975 ZOE AVE	Huntington Park	CA
FQHCLA81D	Terminated	BPS-LAL-009880	NORTHEAST COMMUNITY CLINIC	FOSHAY LEARNING CENTER	3751 S HARVARD BLVD	LOS ANGELES	CA
FQHCLA81F	Terminated	BPS-LAL-009877	NORTHEAST COMMUNITY CLINIC, INC	Northeast Community Clinic - California Family Care	1414 Grand Avenue STE 200	Los Angeles	CA
FQHCLA81G	Terminated	BPS-LAL-009873	NORTHEAST COMMUNITY CLINIC	WOMEN'S HEALTH CENTER	5820 N. FIGUEROA STREET	LOS ANGELES	CA
FQHCLA81K	Active	BPS-LAL-011927	Northeast Community Clinic	Northeast Community Clinic-Hawthorne	4455 W. 117th Street, Suite 300	Hawthorne	CA
FQHCLA81L	Terminated	BPS-LAL-011432	NORTHEAST COMMUNITY CLINIC, INC	Northeast Community Clinic - Elizabeth Health Center	2822 EAST FLORENCE AVENUE	HUNTINGTON PARK	CA
FQHCLA81M	Active	BPS-LAL-012546	NORTHEAST COMMUNITY CLINIC, INC	NECC - Harbor City Health Center	1403 W. LOMITA BLVD STE 100, 101 & 106	HARBOR CITY	CA
FQHCLA81N	Terminated	BPS-LAL-018005	NORTHEAST COMMUNITY CLINIC, INC	Northeast Community Clinic - Sun Valley	8100 SUNLAND BOULEVARD	LOS ANGELES	CA
FQHCLA81P	Terminated	BPS-LAL-018003	NORTHEAST COMMUNITY CLINIC, INC	Northeast Community Clinic - Huntington Park	2822 EAST FLORENCE AVENUE	HUNTINGTON PARK	CA
FQHCLA81Q	Active	BPS-LAL-018004	NORTHEAST COMMUNITY CLINIC, INC	Northeast Community Clinic	1414 SOUTH GRAND AVENUE; SUITE 380	LOS ANGELES	CA
FQHCLA81R	Terminated	BPS-LAL-018002	NORTHEAST COMMUNITY CLINIC, INC	Northeast Community Clinic	1403 LOMITA BOULEVARD, SUITE 103	Harbor City	CA
FQHCLA81S	Active	BPS-LAL-019144	NORTHEAST COMMUNITY CLINIC, INC	NORTHEAST COMMUNITY CLINIC	1414 S GRAND AVE STE 456	LOS ANGELES	CA
FQHCLA81T	Active	BPS-LAL-024835	NORTHEAST COMMUNITY CLINIC, INC	Northeast Community Clinic	4455 W 117th St Ste 502	Hawthorne	CA
FQHCLA81U	Active	BPS-LAL-009876	NORTHEAST COMMUNITY CLINIC, INC	Northeast Community Clinic Mobile Medical Van	5820 N Figueroa St	Los Angeles	CA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
FQHCLA81	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	04/01/2016	07/01/2017
FQHCLA81R	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	07/01/2023	01/31/2024
FQHCLA81Q	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	07/01/2023	01/31/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09665	5944 N FIGUEROA ST	LOS ANGELES	CA	90042	01/01/2019	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08860	11831 HAWTHORNE BOULEVARD	HAWTHORNE	CA	90250	01/01/2019	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09626	1701 SOUTH WESTERN AVENUE	LOS ANGELES	CA	90006	01/01/2019	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #4019	5837 S. CENTRAL AVE.	LOS ANGELES	CA	90001	10/01/2019	04/20/2022
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 05809	4775 W. ROSECRANS AVE.	HAWTHORNE	CA	90250	10/01/2019	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08835	3710 TWEEDY BOULEVARD	SOUTH GATE	CA	90280	10/01/2019	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08837	222 N. MARKET ST.	INGLEWOOD	CA	90301	10/01/2019	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08840	311W. PACIFIC COAST HWY. SUITE C	WILMINGTON	CA	90744	10/01/2019	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08853	1645 EAST 103RD STREET	LOS ANGELES	CA	90002	10/01/2019	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08892	5822 SOUTH VERMONT AVENUE	LOS ANGELES	CA	90044	10/01/2019	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09501	2655 SANTA ANA STREET	SOUTH GATE	CA	90280	10/01/2019	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09564	15700 SOUTH WESTERN AVENUE	GARDENA	CA	90247	10/01/2019	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09580	5101 OBAMA BLVD	LOS ANGELES	CA	90016	10/01/2019	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09582	3741 CRENSHAW BOULEVARD	LOS ANGELES	CA	90016	10/01/2019	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09584	4345 WEST CENTURY BOULEVARD	INGLEWOOD	CA	90304	10/01/2019	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09588	15103 HAWTHORNE BOULEVARD	LAWNDALE	CA	90260	10/01/2019	09/01/2023
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09596	5960 PACIFIC BOULEVARD	HUNTINGTON PARK	CA	90255	10/01/2019	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09686	4707 VENICE BLVD	LOS ANGELES	CA	90019	10/01/2019	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY #10292	4030 SOUTH WESTERN AVE.	LOS ANGELES	CA	90062	10/01/2019	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16747	2626 COLORADO BLVD	LOS ANGELES	CA	90041	10/01/2019	04/20/2022
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08858	7101 ATLANTIC AVENUE	BELL	CA	90201	10/01/2019	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09578	3120 W. IMPERIAL HWY.	INGLEWOOD	CA	90303	10/01/2019	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08839	150 WEST CARSON STREET	CARSON	CA	90745	10/01/2022	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16206	39440 10TH ST W	PALMDALE	CA	93551	10/01/2022	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY # 17699	3131 S. HOOVER STREET UNIT 9-A	LOS ANGELES	CA	90089	10/01/2022	02/21/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09478	3020 SEPULVEDA BOULEVARD	TORRANCE	CA	90505	10/01/2022	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16649	3535 S LA CIENEGA BLVD	LOS ANGELES	CA	90016	10/01/2022	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY #10663	1919 SOUTH HOOVER STREET	LOS ANGELES	CA	90007	10/01/2022	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17631	735 S FIGUEROA ST	LOS ANGELES	CA	90017	10/01/2022	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09857	800 W. WHITTIER BLVD.	MONTEBELLO	CA	90640	10/01/2022	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10309	210 WEST 7TH STREET	LOS ANGELES	CA	90014	10/01/2022	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08897	3361 MARKET ST.	RIVERSIDE	CA	92501	10/01/2022	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09531	4501 WEST SLAUSON AVENUE	LOS ANGELES	CA	90043	10/01/2022	04/01/2024
FQHCLA81C	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09543	2001 PACIFIC COAST HIGHWAY	LOMITA	CA	90717	10/01/2022	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09478	3020 SEPULVEDA BOULEVARD	TORRANCE	CA	90505	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09580	5101 OBAMA BLVD	LOS ANGELES	CA	90016	04/01/2024	03/05/2025
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09582	3741 CRENSHAW BOULEVARD	LOS ANGELES	CA	90016	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08840	311W. PACIFIC COAST HWY. SUITE C	WILMINGTON	CA	90744	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY #10663	1919 SOUTH HOOVER STREET	LOS ANGELES	CA	90007	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09531	4501 WEST SLAUSON AVENUE	LOS ANGELES	CA	90043	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09543	2001 PACIFIC COAST HIGHWAY	LOMITA	CA	90717	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09686	4707 VENICE BLVD	LOS ANGELES	CA	90019	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09578	3120 W. IMPERIAL HWY.	INGLEWOOD	CA	90303	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08897	3361 MARKET ST.	RIVERSIDE	CA	92501	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09596	5960 PACIFIC BOULEVARD	HUNTINGTON PARK	CA	90255	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08837	222 N. MARKET ST.	INGLEWOOD	CA	90301	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08835	3710 TWEEDY BOULEVARD	SOUTH GATE	CA	90280	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10309	210 WEST 7TH STREET	LOS ANGELES	CA	90014	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08858	7101 ATLANTIC AVENUE	BELL	CA	90201	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09501	2655 SANTA ANA STREET	SOUTH GATE	CA	90280	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17631	735 S FIGUEROA ST	LOS ANGELES	CA	90017	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY # 2396	3335 S. FIGUEROA ST., UNIT Q	LOS ANGELES	CA	90007	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08839	150 WEST CARSON STREET	CARSON	CA	90745	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09584	4345 WEST CENTURY BOULEVARD	INGLEWOOD	CA	90304	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08853	1645 EAST 103RD STREET	LOS ANGELES	CA	90002	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 05809	4775 W. ROSECRANS AVE.	HAWTHORNE	CA	90250	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16649	3535 S LA CIENEGA BLVD	LOS ANGELES	CA	90016	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY #10292	4030 SOUTH WESTERN AVE.	LOS ANGELES	CA	90062	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08860	11831 HAWTHORNE BOULEVARD	HAWTHORNE	CA	90250	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16206	39440 10TH ST W	PALMDALE	CA	93551	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09626	1701 SOUTH WESTERN AVENUE	LOS ANGELES	CA	90006	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08892	5822 SOUTH VERMONT AVENUE	LOS ANGELES	CA	90044	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09564	15700 SOUTH WESTERN AVENUE	GARDENA	CA	90247	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09857	800 W. WHITTIER BLVD.	MONTEBELLO	CA	90640	04/01/2024
FQHCLA81B	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09665	5944 N FIGUEROA ST	LOS ANGELES	CA	90042	04/01/2024
FQHCLA81B	LOS ANGELES COUNTY HEALTH SERVICES CENTRAL PHARMACY	313 N FIGUEROA STREET	SUITE 1225	LOS ANGELES	CA	90012	07/01/2015	01/31/2024
FQHCLA81C	LOS ANGELES COUNTY HEALTH SERVICES CENTRAL PHARMACY	313 N FIGUEROA STREET	SUITE 1225	LOS ANGELES	CA	90012	07/01/2015	01/31/2024
FQHCLA81D	LOS ANGELES COUNTY HEALTH SERVICES CENTRAL PHARMACY	313 N FIGUEROA STREET	SUITE 1225	LOS ANGELES	CA	90012	07/01/2015	01/01/2018
FQHCLA81F	LOS ANGELES COUNTY HEALTH SERVICES CENTRAL PHARMACY	313 N FIGUEROA STREET	SUITE 1225	LOS ANGELES	CA	90012	07/01/2015	07/01/2019
FQHCLA81G	LOS ANGELES COUNTY HEALTH SERVICES CENTRAL PHARMACY	313 N FIGUEROA STREET	SUITE 1225	LOS ANGELES	CA	90012	07/01/2015	04/01/2020
FQHCLA81K	LOS ANGELES COUNTY HEALTH SERVICES CENTRAL PHARMACY	313 N FIGUEROA STREET	SUITE 1225	LOS ANGELES	CA	90012	07/01/2015	01/31/2024
FQHCLA81L	LOS ANGELES COUNTY HEALTH SERVICES CENTRAL PHARMACY	313 N FIGUEROA STREET	SUITE 1225	LOS ANGELES	CA	90012	07/01/2015	04/01/2017
FQHCLA81M	LOS ANGELES COUNTY HEALTH SERVICES CENTRAL PHARMACY	313 N FIGUEROA STREET	SUITE 1225	LOS ANGELES	CA	90012	07/01/2015	01/31/2024
FQHCLA81G	OWL REXALL DRUG		5634 N FIGUEROA ST	LOS ANGELES	CA	90042	04/01/2017	02/24/2017
FQHCLA81	RALPHS GROCERY CO	DBA RALPHS #132	1770 CARSON ST	TORRANCE	CA	90501	01/01/2015	07/01/2017
FQHCLA81	RALPHS GROCERY CO	DBA RALPHS #295	8626 FIRESTONE BLVD	DOWNEY	CA	90241	01/01/2015	07/01/2017
FQHCLA81C	RALPHS GROCERY CO	DBA RALPHS #132	1770 CARSON ST	TORRANCE	CA	90501	07/01/2017	06/19/2022
FQHCLA81C	RALPHS GROCERY CO	DBA RALPHS #295	8626 FIRESTONE BLVD	DOWNEY	CA	90241	07/01/2017	06/19/2022
FQHCLA81C	RALPHS GROCERY CO	DBA RALPHS STORE #21	1745 GARFIELD AVENUE	SOUTH PASADENA	CA	91030	07/01/2017	06/19/2022
FQHCLA81M	RALPHS GROCERY CO	DBA RALPHS #132	1770 CARSON ST	TORRANCE	CA	90501	01/01/2020	06/19/2022
FQHCLA81K	RALPHS GROCERY CO	DBA RALPHS #132	1770 CARSON ST	TORRANCE	CA	90501	01/01/2020	06/19/2022
FQHCLA81B	RALPHS GROCERY CO	DBA RALPHS #295	8626 FIRESTONE BLVD	DOWNEY	CA	90241	10/01/2020	06/19/2022
FQHCLA81	RALPHS GROCERY CO.	DBA: RALPHS #022	645 W. 9TH ST.	LOS ANGELES	CA	90015	01/01/2015	07/01/2017
FQHCLA81C	RALPHS GROCERY CO.	DBA: RALPHS #022	645 W. 9TH ST.	LOS ANGELES	CA	90015	07/01/2017	01/05/2024
FQHCLA81Q	RALPHS GROCERY CO.	DBA: RALPHS #022	645 W. 9TH ST.	LOS ANGELES	CA	90015	07/01/2020	01/05/2024
FQHCLA81B	RALPHS GROCERY CO.	DBA: RALPHS #022	645 W. 9TH ST.	LOS ANGELES	CA	90015	10/01/2020	01/05/2024
FQHCLA81	RX E-FILL SOLUTIONS	28341 CONSTELLATION RD		SANTA CLARITA	CA	91355	04/01/2016	07/01/2017
FQHCLA81B	RX E-FILL SOLUTIONS	28341 CONSTELLATION RD		SANTA CLARITA	CA	91355	04/01/2016	01/31/2024
FQHCLA81C	RX E-FILL SOLUTIONS	28341 CONSTELLATION RD		SANTA CLARITA	CA	91355	04/01/2016	01/31/2024
FQHCLA81D	RX E-FILL SOLUTIONS	28341 CONSTELLATION RD		SANTA CLARITA	CA	91355	04/01/2016	01/01/2018
FQHCLA81F	RX E-FILL SOLUTIONS	28341 CONSTELLATION RD		SANTA CLARITA	CA	91355	04/01/2016	07/01/2019
FQHCLA81G	RX E-FILL SOLUTIONS	28341 CONSTELLATION RD		SANTA CLARITA	CA	91355	04/01/2016	04/01/2020
FQHCLA81K	RX E-FILL SOLUTIONS	28341 CONSTELLATION RD		SANTA CLARITA	CA	91355	04/01/2016	01/31/2024
FQHCLA81L	RX E-FILL SOLUTIONS	28341 CONSTELLATION RD		SANTA CLARITA	CA	91355	04/01/2016	04/01/2017
FQHCLA81M	RX E-FILL SOLUTIONS	28341 CONSTELLATION RD		SANTA CLARITA	CA	91355	04/01/2016	01/31/2024
FQHCLA81Q	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	07/01/2023	01/31/2024
FQHCLA81R	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	07/01/2023	01/31/2024
FQHCLA81	THRIFTY PAYLESS, INC.	RITE AID #5516	108 WEST ANAHEIM STREET	WILMINGTON	CA	90744	10/01/2013	07/01/2017
FQHCLA81	THRIFTY PAYLESS, INC.	RITE AID #5445	4322 SOUTH FIGUEROA STREET	LOS ANGELES	CA	90037	10/01/2013	07/01/2017
FQHCLA81	THRIFTY PAYLESS, INC.	RITE AID #5450	6305 YORK BOULEVARD	LOS ANGELES	CA	90042	10/01/2013	07/01/2017
FQHCLA81	THRIFTY PAYLESS, INC.	RITE AID #5426	1815 SOUTH VERMONT AVENUE	LOS ANGELES	CA	90006	10/01/2013	07/01/2017
FQHCLA81	THRIFTY PAYLESS, INC.	RITE AID #5430	446 EAST WASHINGTON BLVD.	LOS ANGELES	CA	90015	10/01/2013	07/01/2017
FQHCLA81C	THRIFTY PAYLESS, INC.	RITE AID #5516	108 WEST ANAHEIM STREET	WILMINGTON	CA	90744	07/01/2017	04/01/2024
FQHCLA81C	THRIFTY PAYLESS, INC.	RITE AID #5445	4322 SOUTH FIGUEROA STREET	LOS ANGELES	CA	90037	07/01/2017	04/01/2024
FQHCLA81C	THRIFTY PAYLESS, INC.	RITE AID #5450	6305 YORK BOULEVARD	LOS ANGELES	CA	90042	07/01/2017	04/01/2024
FQHCLA81C	THRIFTY PAYLESS, INC.	RITE AID #5426	1815 SOUTH VERMONT AVENUE	LOS ANGELES	CA	90006	07/01/2017	04/01/2024
FQHCLA81C	THRIFTY PAYLESS, INC.	RITE AID #5430	446 EAST WASHINGTON BLVD.	LOS ANGELES	CA	90015	07/01/2017	04/01/2024
FQHCLA81C	THRIFTY PAYLESS, INC.	RITE AID #5423	1534 EAST FLORENCE AVENUE	LOS ANGELES	CA	90001	01/01/2023	04/01/2024
FQHCLA81B	THRIFTY PAYLESS, INC.	RITE AID #5423	1534 EAST FLORENCE AVENUE	LOS ANGELES	CA	90001	04/01/2024	06/11/2025
FQHCLA81B	THRIFTY PAYLESS, INC.	RITE AID #5426	1815 SOUTH VERMONT AVENUE	LOS ANGELES	CA	90006	04/01/2024
FQHCLA81B	THRIFTY PAYLESS, INC.	RITE AID #5516	108 WEST ANAHEIM STREET	WILMINGTON	CA	90744	04/01/2024
FQHCLA81B	THRIFTY PAYLESS, INC.	RITE AID #5450	6305 YORK BOULEVARD	LOS ANGELES	CA	90042	04/01/2024	06/24/2024
FQHCLA81B	THRIFTY PAYLESS, INC.	RITE AID #5430	446 EAST WASHINGTON BLVD.	LOS ANGELES	CA	90015	04/01/2024	05/30/2025
FQHCLA81B	THRIFTY PAYLESS, INC.	RITE AID #5445	4322 SOUTH FIGUEROA STREET	LOS ANGELES	CA	90037	04/01/2024
FQHCLA81	WALGREEN CO	DBA: WALGREENS #10069	11983 HAWTHORNE BLVD	HAWTHORNE	CA	90250	04/01/2015	07/01/2017
FQHCLA81	WALGREEN CO	DBA: WALGREENS #11785	6100 PACIFIC BLVD	HUNTINGTON PARK	CA	90255	04/01/2015	07/01/2017
FQHCLA81	WALGREEN CO	DBA: WALGREENS #9882	331 N PACIFIC COAST HWY	EL SEGUNDO	CA	90245-4444	04/01/2015	07/01/2017
FQHCLA81C	WALGREEN CO	DBA: WALGREENS #10069	11983 HAWTHORNE BLVD	HAWTHORNE	CA	90250	07/01/2017	04/01/2024
FQHCLA81C	WALGREEN CO	DBA: WALGREENS #11785	6100 PACIFIC BLVD	HUNTINGTON PARK	CA	90255	07/01/2017	07/15/2018
FQHCLA81C	WALGREEN CO	DBA: WALGREENS #9882	331 N PACIFIC COAST HWY	EL SEGUNDO	CA	90245-4444	07/01/2017	12/21/2022
FQHCLA81B	WALGREEN CO	DBA: WALGREENS #10069	11983 HAWTHORNE BLVD	HAWTHORNE	CA	90250	04/01/2024
FQHCLA81	WALGREEN CO.	DBA: WALGREENS # 07482	1800 W SLAUSON	LOS ANGELES	CA	90047-1126	04/01/2015	07/01/2017
FQHCLA81	WALGREEN CO.	DBA: WALGREENS # 07016	3724 CRENSHAW BLVD	LOS ANGELES	CA	90016	04/01/2015	07/01/2017
FQHCLA81	WALGREEN CO.	DBA: WALGREENS #12913	1500 E GAGE AVE	LOS ANGELES	CA	90001	04/01/2015	07/01/2017
FQHCLA81	WALGREEN CO.	DBA: WALGREENS # 05879	3201 WEST 6TH ST	LOS ANGELES	CA	90020	04/01/2015	07/01/2017
FQHCLA81	WALGREEN CO.	DBA: WALGREENS # 06974	3331 WEST CENTURY BLVD	INGLEWOOD	CA	90303	04/01/2015	07/01/2017
FQHCLA81	WALGREEN CO.	DBA: WALGREENS # 09137	14250 PRAIRIE AVE	HAWTHORNE	CA	90250-7908	04/01/2015	07/01/2017
FQHCLA81	WALGREEN CO.	DBA: WALGREENS #12460	617 W 7TH ST STE 100	LOS ANGELES	CA	90017	04/01/2015	07/01/2017
FQHCLA81	WALGREEN CO.	DBA: WALGREENS # 06413	230 N LABREA AVE	INGLEWOOD	CA	90301	04/01/2015	07/01/2017
FQHCLA81C	WALGREEN CO.	DBA: WALGREENS # 07482	1800 W SLAUSON	LOS ANGELES	CA	90047-1126	07/01/2017	07/15/2018
FQHCLA81C	WALGREEN CO.	DBA: WALGREENS # 07016	3724 CRENSHAW BLVD	LOS ANGELES	CA	90016	07/01/2017	07/15/2018
FQHCLA81C	WALGREEN CO.	DBA: WALGREENS #12913	1500 E GAGE AVE	LOS ANGELES	CA	90001	07/01/2017	07/15/2018
FQHCLA81C	WALGREEN CO.	DBA: WALGREENS # 05879	3201 WEST 6TH ST	LOS ANGELES	CA	90020	07/01/2017	07/15/2018
FQHCLA81C	WALGREEN CO.	DBA: WALGREENS # 06974	3331 WEST CENTURY BLVD	INGLEWOOD	CA	90303	07/01/2017	04/01/2024
FQHCLA81C	WALGREEN CO.	DBA: WALGREENS # 09137	14250 PRAIRIE AVE	HAWTHORNE	CA	90250-7908	07/01/2017	04/01/2024
FQHCLA81C	WALGREEN CO.	DBA: WALGREENS #12460	617 W 7TH ST STE 100	LOS ANGELES	CA	90017	07/01/2017	07/15/2018
FQHCLA81C	WALGREEN CO.	DBA: WALGREENS # 06413	230 N LABREA AVE	INGLEWOOD	CA	90301	07/01/2017	07/15/2018
FQHCLA81C	WALGREEN CO.	DBA: WALGREENS # 05879	3201 WEST 6TH ST	LOS ANGELES	CA	90020	04/01/2023	04/01/2024
FQHCLA81C	WALGREEN CO.	DBA: WALGREENS # 07482	1800 W SLAUSON	LOS ANGELES	CA	90047-1126	04/01/2023	04/01/2024
FQHCLA81B	WALGREEN CO.	DBA: WALGREENS # 06974	3331 WEST CENTURY BLVD	INGLEWOOD	CA	90303	04/01/2024
FQHCLA81B	WALGREEN CO.	DBA: WALGREENS # 05879	3201 WEST 6TH ST	LOS ANGELES	CA	90020	04/01/2024
FQHCLA81B	WALGREEN CO.	DBA: WALGREENS # 09137	14250 PRAIRIE AVE	HAWTHORNE	CA	90250-7908	04/01/2024
FQHCLA81B	WALGREEN CO.	DBA: WALGREENS # 07482	1800 W SLAUSON	LOS ANGELES	CA	90047-1126	04/01/2024
FQHCLA81	WALGREENS MAIL SERVICE, INC.		8337 S PARK CIRCLE	ORLANDO	FL	32819-9049	04/01/2015	07/01/2017
FQHCLA81	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	04/01/2015	07/01/2017

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	2/26/2024 6:37:29 PM	3/4/2025 8:13:44 PM	3/4/2025 8:13 PM
Details	Last Recertification Date	Update	Recertification	2/24/2023 6:24:52 PM	2/26/2024 6:37:29 PM	2/26/2024 6:37 PM
Contacts	Primary Contact	Update	Profile Change Request	Orozco, Emely Pharmacy Program Coordinator Northeast Community Clinic 6264575209	Orozco, Emely Pharmacy Program Administrator Northeast Community Clinic 6264575209	9/5/2023 11:54 AM
Details	Last Recertification Date	Update	Recertification	2/28/2022 3:02:51 PM	2/24/2023 6:24:52 PM	2/24/2023 6:24 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1336790914 (CA)		10/14/2022 2:58 PM
Contacts	Primary Contact	Update	Change Request	Vega, Livier Pharmacy Administrator Northeast Community Clinic 6264575209	Orozco, Emely Pharmacy Program Coordinator Northeast Community Clinic 6264575209	4/25/2022 11:48 AM
Details	Last Recertification Date	Update	Recertification	2/25/2021 5:29:21 PM	2/28/2022 3:02:51 PM	2/28/2022 3:02 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	2/25/2021 5:29 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	2/25/2021 5:29 PM
Contacts	Primary Contact	Update	Recertification	Carrillo, Bernardo OPERATIONS DIRECTOR Northeast Community Clinic 6264576900	Vega, Livier Pharmacy Administrator Northeast Community Clinic 6264575209	2/25/2021 5:29 PM
Details	Last Recertification Date	Update	Recertification	2/20/2020 7:18:21 PM	2/25/2021 5:29:21 PM	2/25/2021 5:29 PM
Contacts	Primary Contact	Update	Change Request	Carrillo, Bernard Operations Director Northeast Community Clinic 6264576900	Carrillo, Bernardo OPERATIONS DIRECTOR Northeast Community Clinic 6264576900	10/14/2020 7:38 AM
Contacts	Primary Contact	Update	Change Request	Patel, Nilam A. Executive Assistant Northeast Community Clinic 6264576900	Carrillo, Bernard Operations Director Northeast Community Clinic 6264576900	8/28/2020 8:03 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	1336790914	1124460274	7/15/2020 10:02 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1336790914	7/15/2020 10:02 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1124460274 (CA)		7/15/2020 8:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/15/2020 8:17 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1336790914	7/15/2020 8:17 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	7/15/2020 8:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1336790914 ( )		7/15/2020 8:17 PM
Details	Last Recertification Date	Update	Recertification		2/20/2020 7:18:21 PM	2/20/2020 7:18 PM
Contacts	Primary Contact	Update	Change Request	Pulido Verduzco, Estefania Executive Assistant Northeast Community Clinic 6264576900	Patel, Nilam A. Executive Assistant Northeast Community Clinic 6264576900	2/3/2020 3:28 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1336790914	10/21/2019 11:30 AM
Contacts	Primary Contact	Update	Change Request	Fukui, Keri Executive Assistant Northeast Community Clinic 6264576900	Pulido Verduzco, Estefania Executive Assistant Northeast Community Clinic 6264576900	10/15/2019 1:15 PM
Details	State	Update		Approved	Active	10/1/2019 12:04 AM
Contacts	Primary Contact	Update	Change Request	Pulido Verduzco, Estefania Executive Assistant Northeast Community Clinic 6264576900	Fukui, Keri Executive Assistant Northeast Community Clinic 6264576900	9/12/2019 4:38 PM
Contacts	Signed By	Insert	New Registration		LAU, CHRISTOPHER EXECUTIVE DIRECTOR Northeast Community Clinic 6264576900	8/5/2019 11:28 AM
Details	340B ID	Update	New Registration		FQHCLA81T	8/5/2019 11:28 AM
Dates	Participating Approval Date	Update	New Registration		8/5/2019 11:28:54 AM	8/5/2019 11:28 AM
Details	State	Update	New Registration	Pending	Approved	8/5/2019 11:28 AM
Dates	Signed By Date	Update	New Registration		7/10/2019 1:52:52 PM	8/5/2019 11:28 AM
Dates	Start Date	Update	New Registration		10/1/2019 12:00:00 AM	8/5/2019 11:28 AM
Addresses	Main Address	Insert	New Registration		4455 W 117th St Ste 502 Hawthorne, CA 90250-2261	7/2/2019 7:11 PM
Addresses	Billing Address	Insert	New Registration		Northeast Community Clinic 2550 West Main Street 301 Alhambra, CA 91801	7/2/2019 7:11 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/2/2019 7:11 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1124460274	7/2/2019 7:11 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	7/2/2019 7:11 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1124460274	7/2/2019 7:11 PM
Contacts	Primary Contact	Insert	New Registration		Pulido Verduzco, Estefania Executive Assistant Northeast Community Clinic 6264576900	7/2/2019 7:11 PM
Contacts	Authorizing Official	Insert	New Registration		LAU, CHRISTOPHER EXECUTIVE DIRECTOR Northeast Community Clinic 6264576900	7/2/2019 7:11 PM
Details	Last Recertification Date	Insert	New Registration			7/2/2019 7:11 PM
Details	Grant Number	Insert	New Registration		LALCS00033	7/2/2019 7:11 PM
Details	340B ID	Insert	New Registration			7/2/2019 7:11 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/2/2019 7:11 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/2/2019 7:11 PM
Details	Medicare Provider Number	Insert	New Registration			7/2/2019 7:11 PM
Details	Entity Name	Insert	New Registration		NORTHEAST COMMUNITY CLINIC, INC	7/2/2019 7:11 PM
Details	Program Code	Insert	New Registration		FQHCLA	7/2/2019 7:11 PM
Details	Entity Subname	Insert	New Registration		Northeast Community Clinic	7/2/2019 7:11 PM
Dates	Participating Approval Date	Insert	New Registration			7/2/2019 7:11 PM
Details	State	Insert	New Registration		Pending	7/2/2019 7:11 PM
Dates	Registration Date	Insert	New Registration		7/2/2019 7:11:24 PM	7/2/2019 7:11 PM
Dates	Signed By Date	Insert	New Registration			7/2/2019 7:11 PM
Dates	Start Date	Insert	New Registration			7/2/2019 7:11 PM
Terminations	Termination Comments	Insert	New Registration			7/2/2019 7:11 PM
Terminations	Termination Date	Insert	New Registration			7/2/2019 7:11 PM
Terminations	Termination Effective Date	Insert	New Registration			7/2/2019 7:11 PM
Terminations	Termination Reason	Insert	New Registration			7/2/2019 7:11 PM

340B Drug Pricing Program Database