Covered Entity Details

CH10252D Seattle Roots Community Health (Active) - information as of 5/12/2025 10:07:53 PM

Main Details

Name

Seattle Roots Community Health

Subdivision Name

Seattle Roots at Meany School Clinic

Type

HRSA-Funded Health Center

Site ID

BPS-H80-028334

340B ID

CH10252D

Grant Number

H80CS00647

Additional Details

Current Program Status

Active

Registration Date

11/12/2019

Participating Start Date

1/1/2020

Participating Approval Date

12/2/2019

Last Recertification Date

2/26/2025

Contacts

Authorizing Official

Country Doctor Community Clinic
Bessie Chi, Director of Pharmacy
(206) 709-7116

Primary Contact

Country Doctor Community Clinic
Angie Treptow, Revenue and Reimbursement Manager
(206) 299-1937

Addresses

Street Address

301 21st Ave E
Seattle, WA 98112-5318

Billing Address

seattle roots community health
2101 E Yesler Way
Suite 210
Seattle, WA 98122

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
WA	2144234	1356999288

Shipping Addresses

Shipping Address 1

Seattle Roots Community Health
2101 E Yesler Way
Seattle, WA 98122

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
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1993	2201 E MADISON ST	SEATTLE	WA	98112	04/15/2024	07/01/2024			07/01/2024

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH102520	Active	BPS-H80-002722	Seattle Roots Community Health	Seattle Roots at Country Doctor	500 19th Ave E	Seattle	WA
CH10252A	Active	BPS-H80-002833	Seattle Roots Community Health	Seattle Roots at Carolyn Downs	2101 E. YESLER WAY	SEATTLE	WA
CH10252B	Terminated	BPS-H80-013411	COUNTRY DOCTOR COMMUNITY CLINIC	CDCHC After Hours Clinic	550 16th Ave STE 100	Seattle	WA
CH10252C	Active	BPS-H80-003555	Seattle Roots Community Health	Seattle Roots Dental Clinic	510 19th Ave E	Seattle	WA
CH10252D	Active	BPS-H80-028334	Seattle Roots Community Health	Seattle Roots at Meany School Clinic	301 21st Ave E	Seattle	WA
CH10252E	Active	BPS-H80-031334	Seattle Roots Community Health	Seattle Roots at Step Clinic	1621 S Jackson St STE 201 RM 1	SEATTLE	WA
CH10252F	Active	BPS-H80-030875	Seattle Roots Community Health	Seattle Roots at Nova	2410 E Cherry St	Seattle	WA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH102520	AIDS HEALTHCARE FOUNDATION	AHF PHARMACY	1016 E PIKE ST STE 100	SEATTLE	WA	98122	04/01/2014
CH102520	AIDS HEALTHCARE FOUNDATION	AHF PHARMACY	901 BOREN AVE SUITE 800	SEATTLE	WA	98104-3534	10/01/2014	05/22/2024
CH102520	ALTO PHARMACY, LLC	DBA ALTO PHARMACY	13010 NE 20TH ST STE 200	BELLEVUE	WA	98005-2034	10/01/2021	02/17/2023
CH102520	ALTO PHARMACY, LLC	DBA ALTO PHARMACY	1400 TENNESSEE ST UNIT 2	SAN FRANCISCO	CA	94107-3421	10/01/2021	02/17/2023
CH102520	BARTELL DRUGS #06908	9600 15TH S.W		SEATTLE	WA	98106	01/01/2016	09/28/2023
CH102520	BARTELL DRUGS #06909	100 NO 85TH ST		SEATTLE	WA	98103	01/01/2016	10/13/2022
CH102520	BARTELL DRUGS #06914	1820 N 45TH ST		SEATTLE	WA	98103-6803	01/01/2016	09/01/2021
CH102520	BARTELL DRUGS #06923	1407 BROADWAY		SEATTLE	WA	98122	10/01/2014	10/13/2022
CH102520	BARTELL DRUGS #06924	6401 12TH AVE NE		SEATTLE	WA	98115	01/01/2016	01/01/2024
CH102520	BARTELL DRUGS #06931	2700 NE UNIVERSITY VILLAGE ST		SEATTLE	WA	98105	01/01/2016	10/13/2022
CH102520	BARTELL DRUGS #06936	1001 MERCER ST		SEATTLE	WA	98109-4324	07/01/2019	06/03/2019
CH102520	BARTELL DRUGS #06941	14901 4TH AVENUE SW SUITE 100		BURIEN	WA	98166	01/01/2016
CH102520	BARTELL DRUGS #06942	600 FIRST AVENUE NORTH		SEATTLE	WA	98109	01/01/2016	09/10/2023
CH102520	BARTELL DRUGS #06943	14277 PACIFIC HIGHWAY SOUTH		TUKWILA	WA	98168	01/01/2016	10/13/2022
CH102520	BARTELL DRUGS #06959	653 156TH AVE NE		BELLEVUE	WA	98007-4823	07/01/2019	06/03/2019
CH102520	BARTELL DRUGS #06962	18420 AURORA AVENUE NO.		SHORELINE	WA	98133	01/01/2016	09/01/2021
CH102520	BARTELL DRUGS #06963	2345 RAINIER AVENUE SOUTH		SEATTLE	WA	98144	10/01/2014
CH102520	BARTELL DRUGS #06972	400 S JACKSON ST # 300		SEATTLE	WA	98104-4417	07/01/2019	06/03/2019
CH102520	BARTELL PHARMACY DISTRIBUTION	4140 EAST MARGINAL WAY SO.		SEATTLE	WA	98134	10/01/2014	09/01/2021
CH102520	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	01/01/2021	12/16/2024
CH102520	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	01/01/2021
CH102520	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	01/01/2021	12/16/2024
CH102520	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	01/01/2021	12/16/2024
CH102520	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	01/01/2021	12/16/2024
CH102520	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	01/01/2021
CH102520	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	01/01/2021	12/16/2024
CH102520	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	01/01/2021	12/16/2024
CH102520	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	01/01/2021
CH102520	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	01/01/2021
CH102520	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	07/01/2025
CH102520	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	01/01/2021
CH102520	EVERGREEN PHARMACEUTICAL LLC	OMNICARE OF SEATTLE	12674 GATEWAY DR S	TUKWILA	WA	98168-3307	04/01/2023
CH102520	FRED MEYER PHARMACY	100 N.W. 85TH		SEATTLE	WA	98117	10/01/2015	11/16/2024
CH102520	FRED MEYER STORES	915 NW 45TH STREET		SEATTLE	WA	98107	10/01/2015	01/23/2018
CH102520	FRED MEYER STORES	FRED MEYER PHARMACY #459	365 RENTON CENTER WAY SW	RENTON	WA	98057-2324	07/01/2019	11/16/2024
CH102520	FRED MEYER STORES INC	FRED MEYER PHARMACY 13	18325 AURORA AVE N	SHORELINE	WA	98133-4417	10/01/2015	11/16/2024
CH102520	FRED MEYER STORES INC	13000 LAKE CITY WAY NE		SEATTLE	WA	98125-4429	10/01/2015
CH102520	HEALTHY OPTIONS INC	DBA POSTAL PRESCRIPTION SVCS	3500 SE 26TH AVE PO BOX 2718	PORTLAND	OR	97202	10/01/2015
CH102520	KELLEY-ROSS LONG TERM CARE PHARMACY	2324 EASTLAKE AVE E STE 400		SEATTLE	WA	98102-6539	07/01/2018	02/28/2023
CH102520	KELLEY-ROSS PHARMACY	904 7TH AVE # 103		SEATTLE	WA	98104-1132	07/01/2019
CH102520	METMEDS	METROPOLITAN MEDICATIONS LLC	5707 LACEY BLVD SE STE 103	LACEY	WA	98503	07/01/2019	02/13/2024
CH102520	PHARMACY4HUMANITY	AHF PHARMACY	901 BOREN AVE., STE. 800	SEATTLE	WA	98104	05/23/2024
CH102520	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	01/01/2021
CH102520	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2926	1001 MADISON ST.	SEATTLE	WA	98104	01/01/2018
CH102520	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	01/01/2021
CH102520	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	01/01/2021
CH102520	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	01/01/2021
CH102520	QFC PHARMACY #807	2746 NE 45TH		SEATTLE	WA	98105	10/01/2015	01/23/2018
CH102520	QFC PHARMACY #887	417 BROADWAY EAST		SEATTLE	WA	98102	10/01/2014
CH102520	SAFEWAY INC	SAFEWAY PHARMACY #1508	3820 RAINER AVE S.	SEATTLE	WA	98118	10/01/2014	05/12/2017
CH102520	SAFEWAY INC	SAFEWAY PHARMACY #1551	1410 E JOHN ST	SEATTLE	WA	98112	10/01/2014
CH102520	SAFEWAY INC	SAFEWAY PHARMACY #1993	2201 E MADISON ST	SEATTLE	WA	98112	10/01/2014
CH102520	SAFEWAY INC	SAFEWAY PHARMACY #1493	4011 S 164TH ST	SEATAC	WA	98188-3067	10/01/2015	05/12/2017
CH102520	SAFEWAY INC	SAFEWAY PHARMACY #1550	7300 ROOSEVELT WAY NE	SEATTLE	WA	98115	10/01/2015
CH102520	SAFEWAY INC	SAFEWAY PHARMACY #1965	9262 RAINIER AVE S	SEATTLE	WA	98118	10/01/2015	07/23/2017
CH102520	SAFEWAY INC	SAFEWAY PHARMACY #3540	21401 PACIFIC HWY SOUTH	DES MOINES	WA	98198	10/01/2015
CH10252F	SAFEWAY INC	SAFEWAY PHARMACY #3540	21401 PACIFIC HWY SOUTH	DES MOINES	WA	98198	07/01/2024
CH10252C	SAFEWAY INC	SAFEWAY PHARMACY #1551	1410 E JOHN ST	SEATTLE	WA	98112	07/01/2024	04/15/2024
CH10252D	SAFEWAY INC	SAFEWAY PHARMACY #1993	2201 E MADISON ST	SEATTLE	WA	98112	07/01/2024
CH10252C	SAFEWAY INC	SAFEWAY PHARMACY #1551	1410 E JOHN ST	SEATTLE	WA	98112	10/01/2024
CH102520	SEATTLEMEDS PHARMACY		1305 MADISON STREET	SEATTLE	WA	98104	04/01/2013	05/26/2017
CH10252A	SEATTLEMEDS PHARMACY		1305 MADISON STREET	SEATTLE	WA	98104	04/01/2013	05/26/2017
CH102520	UNION CENTER PHARMACY	2324 EASTLAKE AVE E STE 405		SEATTLE	WA	98102-6536	07/01/2018	02/25/2019
CH102520	WALGREEN CO	DBA; WALGREENS #10995	3716 S 144TH STREET	TUKWILA	WA	98168	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS # 03515	8701 GREENWOOD AVE N	SEATTLE	WA	98103	07/01/2013	01/18/2017
CH102520	WALGREEN CO.	DBA: WALGREENS # 03518	25605 104TH AVE SE	KENT	WA	98030	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS # 03582	14352 LAKE CITY WAY NE	SEATTLE	WA	98125	07/01/2013	11/07/2023
CH102520	WALGREEN CO.	DBA: WALGREENS # 03604	5409 15TH AVENUE NW	SEATTLE	WA	98107	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS # 03632	2400 S. JACKSON ST.	SEATTLE	WA	98144	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS # 03662	647 140TH AVENUE NE	BELLEVUE	WA	98005	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS # 03788	14510 AURORA AVE N	SHORELINE	WA	98133-6525	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS # 03840	14656 AMBAUM BLVD SW	BURIEN	WA	98166	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS # 04156	12405 NE 85TH ST.	KIRKLAND	WA	98033	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS # 04157	859 NE NORTHGATE WAY	SEATTLE	WA	98125	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS # 04627	275 RAINIER AVENUE S	RENTON	WA	98057	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS # 04759	17518 15TH AVE NE	SHORELINE	WA	98155	07/01/2013	02/28/2019
CH102520	WALGREEN CO.	DBA: WALGREENS # 04898	6330 35TH AVE. SW	SEATTLE	WA	98126	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS # 05950	4412 RAINIER AVE S	SEATTLE	WA	98118	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS # 06194	222 PIKE STREET	SEATTLE	WA	98101-3635	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS # 06259	9456 16TH AVE SW	SEATTLE	WA	98106-2824	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS # 06357	6300 E LAKE SAMMAMISH PKY SE	ISSAQUAH	WA	98029	07/01/2013	12/08/2022
CH102520	WALGREEN CO.	DBA: WALGREENS # 06389	8500 15TH AVE NW STE A	SEATTLE	WA	98117	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS #06590	1531 BROADWAY	SEATTLE	WA	98122-3810	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS # 06614	20812 BOTHELL EVERETT HWY	BOTHELL	WA	98021-8409	07/01/2013	12/08/2022
CH102520	WALGREEN CO.	DBA: WALGREENS # 06890	500 15TH AVE EAST	SEATTLE	WA	98112-4513	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS # 06901	28817 MILITARY ROAD SOUTH	FEDERAL WAY	WA	98003	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS # 07352	1205 NE 50TH STREET	SEATTLE	WA	98105-4406	07/01/2013	11/18/2020
CH102520	WALGREEN CO.	DBA: WALGREENS # 07355	3011 NE SUNSET BLVD	RENTON	WA	98056	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS # 09423	23003 PACIFIC HWY S	DES MOINES	WA	98198-7269	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS #11856	566 DENNY WAY	SEATTLE	WA	98109	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS #13087	4468 STONE WAY N	SEATTLE	WA	98103	07/01/2013
CH102520	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16403	1409 11TH AVE.	SEATTLE	WA	98122	07/01/2013
CH102520	WALGREEN CO.	DBA: WALGREENS # 09373	17524 AURORA AVENUE NORTH	SHORELINE	WA	98133-4813	07/01/2019
CH10252E	WALGREEN CO.	DBA: WALGREENS # 03632	2400 S. JACKSON ST.	SEATTLE	WA	98144	07/01/2024
CH102520	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	07/01/2013	07/07/2015
CH102520	WALGREENS MAIL SERVICE, INC.		8337 S PARK CIRCLE	ORLANDO	FL	32819-9049	07/01/2013	07/07/2015

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Billing Address	Update	Change Request	Country Doctor Community Health Centers 2101 E Yesler Way Suite 210 Seattle, WA 98122	seattle roots community health 2101 E Yesler Way Suite 210 Seattle, WA 98122	4/2/2025 11:05 AM
Addresses	Shipping Address	Update	Change Request	Carolyn Downs Family Med Center 2101 E Yesler Way Seattle, WA 98122	Seattle Roots Community Health 2101 E Yesler Way Seattle, WA 98122	4/2/2025 11:05 AM
Details	Entity Name	Update	Change Request	Country Doctor Community Clinic	Seattle Roots Community Health	4/2/2025 11:05 AM
Details	Entity Subname	Update	Change Request	Meany Middle School - School Based Health Center	Seattle Roots at Meany School Clinic	4/2/2025 11:05 AM
Details	Last Recertification Date	Update	Recertification	2/2/2024 6:10:31 PM	2/26/2025 11:41:16 AM	2/26/2025 11:41 AM
Details	Last Recertification Date	Update	Recertification	2/27/2023 12:23:20 PM	2/2/2024 6:10:31 PM	2/2/2024 6:10 PM
Addresses	Shipping Address	Insert	Recertification		Carolyn Downs Family Med Center 2101 E Yesler Way Seattle, WA 98122	2/27/2023 12:23 PM
Details	Last Recertification Date	Update	Recertification	2/4/2022 1:37:01 PM	2/27/2023 12:23:20 PM	2/27/2023 12:23 PM
Contacts	Authorizing Official	Update	OPA Edit	Treptow, Angie Revenue and Reimbursement Manager Country Doctor Community Clinic 2062991937	Chi, Bessie Director of Pharmacy Country Doctor Community Clinic 2067097116	2/21/2023 6:49 AM
Contacts	Primary Contact	Update	OPA Edit	Chi, Bessie Director of Pharmacy Country Doctor Community Clinic 2067097116	Treptow, Angie Revenue and Reimbursement Manager Country Doctor Community Clinic 2062991937	2/21/2023 6:49 AM
Contacts	Authorizing Official	Update	AO Change Request	Taylor, Meg Chief Financial Officer Country Doctor Community Health Centers 2062991941	Treptow, Angie Revenue and Reimbursement Manager Country Doctor Community Clinic 2062991937	2/16/2023 12:45 PM
Contacts	Primary Contact	Update	Profile Change Request	Chi, Bessie Director of Pharmacy Country Doctor Community Clinic 2062997116	Chi, Bessie Director of Pharmacy Country Doctor Community Clinic 2067097116	8/19/2022 4:55 PM
Details	Last Recertification Date	Update	Recertification	2/11/2021 2:40:10 PM	2/4/2022 1:37:01 PM	2/4/2022 1:37 PM
Contacts	Authorizing Official	Update	AO Change Request	Watts, Raleigh R Executive Director Country Doctor Community Health Centers 2062991628	Taylor, Meg Chief Financial Officer Country Doctor Community Health Centers 2062991941	2/2/2022 6:35 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1356999288 ( )		2/11/2021 2:40 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1356999288	2/11/2021 2:40 PM
Medicaid Billing	NPI: State	Insert	Recertification		WA	2/11/2021 2:40 PM
Details	Last Recertification Date	Update	Recertification	2/14/2020 1:12:29 PM	2/11/2021 2:40:10 PM	2/11/2021 2:40 PM
Contacts	Primary Contact	Update	Profile Change Request	Chi, Bessie Pharmacy Manager Country Doctor Community Clinic 2062997116	Chi, Bessie Director of Pharmacy Country Doctor Community Clinic 2062997116	10/14/2020 9:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/14/2020 1:12 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		2144234	2/14/2020 1:12 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WA	2/14/2020 1:12 PM
Details	Last Recertification Date	Update	Recertification		2/14/2020 1:12:29 PM	2/14/2020 1:12 PM
Contacts	Primary Contact	Update	Profile Change Request	Chi, Bessie Pharmacy Manager Country Doctor Community Clinic 2062991681	Chi, Bessie Pharmacy Manager Country Doctor Community Clinic 2062997116	1/30/2020 4:06 PM
Details	State	Update		Approved	Active	1/1/2020 12:04 AM
Contacts	Signed By	Insert	New Registration		Watts, Raleigh R Executive Director Country Doctor Community Health Centers 2062991628	12/2/2019 4:49 PM
Details	340B ID	Update	New Registration		CH10252D	12/2/2019 4:49 PM
Dates	Participating Approval Date	Update	New Registration		12/2/2019 4:49:47 PM	12/2/2019 4:49 PM
Details	State	Update	New Registration	Pending	Approved	12/2/2019 4:49 PM
Dates	Signed By Date	Update	New Registration		11/15/2019 5:21:15 PM	12/2/2019 4:49 PM
Dates	Start Date	Update	New Registration		1/1/2020 12:00:00 AM	12/2/2019 4:49 PM
Addresses	Main Address	Insert	New Registration		301 21st Ave E Seattle, WA 98112-5318	11/12/2019 2:04 PM
Addresses	Billing Address	Insert	New Registration		Country Doctor Community Health Centers 2101 E Yesler Way Suite 210 Seattle, WA 98122	11/12/2019 2:04 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1356999288	11/12/2019 2:04 PM
Contacts	Primary Contact	Insert	New Registration		Chi, Bessie Pharmacy Manager Country Doctor Community Clinic 2062991681	11/12/2019 2:04 PM
Contacts	Authorizing Official	Insert	New Registration		Watts, Raleigh R Executive Director Country Doctor Community Health Centers 2062991628	11/12/2019 2:04 PM
Details	Last Recertification Date	Insert	New Registration			11/12/2019 2:04 PM
Details	Grant Number	Insert	New Registration		H80CS00647	11/12/2019 2:04 PM
Details	340B ID	Insert	New Registration			11/12/2019 2:04 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			11/12/2019 2:04 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			11/12/2019 2:04 PM
Details	Medicare Provider Number	Insert	New Registration			11/12/2019 2:04 PM
Details	Entity Name	Insert	New Registration		Country Doctor Community Clinic	11/12/2019 2:04 PM
Details	Program Code	Insert	New Registration		CH	11/12/2019 2:04 PM
Details	Entity Subname	Insert	New Registration		Meany Middle School - School Based Health Center	11/12/2019 2:04 PM
Dates	Participating Approval Date	Insert	New Registration			11/12/2019 2:04 PM
Details	State	Insert	New Registration		Pending	11/12/2019 2:04 PM
Dates	Registration Date	Insert	New Registration		11/12/2019 2:04:41 PM	11/12/2019 2:04 PM
Dates	Signed By Date	Insert	New Registration			11/12/2019 2:04 PM
Dates	Start Date	Insert	New Registration			11/12/2019 2:04 PM
Terminations	Termination Comments	Insert	New Registration			11/12/2019 2:04 PM
Terminations	Termination Date	Insert	New Registration			11/12/2019 2:04 PM
Terminations	Termination Effective Date	Insert	New Registration			11/12/2019 2:04 PM
Terminations	Termination Reason	Insert	New Registration			11/12/2019 2:04 PM

340B Drug Pricing Program Database