Covered Entity Details

CH08126J Mountain Family Health Centers (Active) - information as of 5/24/2025 12:41:37 AM

Main Details

Name

Mountain Family Health Centers

Subdivision Name

Mountain Family Health Centers Roaring Fork High School SBHC

Type

HRSA-Funded Health Center

Site ID

BPS-H80-031118

340B ID

CH08126J

Grant Number

H80CS00830

Additional Details

Current Program Status

Active

Registration Date

1/7/2021

Participating Start Date

4/1/2021

Participating Approval Date

1/11/2021

Last Recertification Date

2/11/2025

Contacts

Authorizing Official

Mountain Family Health Centers
Art M Fernandez, Chief Operating Officer
(970) 945-2840 Ext: 7205

Primary Contact

Mountain Family Health Centers
Shiela Kendall, Provider Relations and Credentialing Manager
(970) 945-2840 Ext: 7369

Addresses

Street Address

2270 Highway 133 Rm 14
Carbondale, CO 81623-9271

Billing Address

Mountain Family Health Centers
PO Box 339
Glenwood Springs, CO 81602

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
CO	9000186600	1568073229

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	Address Cont.	City	State
CH081260E	Active	BPS-H80-008779	Mountain Family Health Centers	Mountain Family Health Centers Rifle	195 W. 14th St., Bldg C		Rifle	CO
CH08126B	Active	BPS-H80-002901	Mountain Family Health Centers	Mountain Family Health Centers Glenwood Springs	1905 BLAKE AVE	STE 101	GLENWOOD SPRINGS	CO
CH08126D	Active	BPS-H80-027305	Mountain Family Health Centers	Mountain Family Health Centers Basalt	123 Emma Rd, Ste 106		Basalt	CO
CH08126F	Active	BPS-H80-035663	Mountain Family Health Centers	Mountain Family Health Centers Avon	230 Chapel Square	Unit D-102	Avon	CO
CH08126G	Active	BPS-H80-018203	MOUNTAIN FAMILY HEALTH CENTERS	MOUNTAIN FAMILY HEALTH CENTERS AVON SCHOOL-BASED HEALTH CENTER	0850 West Beaver Creek Blvd		Avon	CO
CH08126H	Terminated	BPS-H80-027260	Mountain Family Health Centers	Mountain Family Health Centers Riverside Administration	2700 Gilstrap Ct Ste 100		Glenwood Springs	CO
CH08126J	Active	BPS-H80-031118	Mountain Family Health Centers	Mountain Family Health Centers Roaring Fork High School SBHC	2270 Highway 133 Rm 14		Carbondale	CO
CH08126K	Terminated	BPS-H80-031880	Mountain Family Health Centers	Mountain Family Health Centers Basalt Middle School SBHC	51 School St Rm E114		Basalt	CO
CH08126L	Terminated	BPS-H80-031879	Mountain Family Health Centers	Mountain Family Health Centers Basalt Elementary School SBHC	151 Cottonwood Dr		Basalt	CO
CH08126M	Active	BPS-H80-031994	Mountain Family Health Centers	Mountain Family Health Centers Glenwood Springs High School SBHC	1521 Grand Ave	Room 1008	Glenwood Springs	CO
CH08126N	Terminated	BPS-H80-031878	Mountain Family Health Centers	Mountain Family Health Centers Basalt High School SBHC	600 Southside Dr Rm 156		Basalt	CO
CH08126P	Terminated	BPS-H80-019590	MOUNTAIN FAMILY HEALTH CENTERS	MOUNTAIN FAMILY HEALTH CENTERS DENTAL VAN.	1905 Blake Ave STE 101		Glenwood Springs	CO
CH08126Q	Active	BPS-H80-036918	Mountain Family Health Centers	Mountain Family Health Centers Gypsum	410 McGregor Drive		Gypsum	CO

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH08126B	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	07/01/2023
CH08126B	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	07/01/2023
CH08126B	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	07/01/2023
CH08126B	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	07/01/2023
CH08126B	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	07/01/2023
CH08126B	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	07/01/2023
CH08126B	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	07/01/2023
CH08126B	AMAZON PHARMACY #001	4500 S PLEASANT VALLEY RD STE 201		AUSTIN	TX	78744-2911	10/01/2018	04/01/2019
CH081260E	AMAZON PHARMACY #001	4500 S PLEASANT VALLEY RD STE 201		AUSTIN	TX	78744-2911	07/01/2019	01/17/2021
CH08126B	AZ PHARMACY, LLC	DBA AMAZON PHARMACY #002	3809 E WATKINS ST	PHOENIX	AZ	85034	04/01/2019	04/01/2019
CH081260E	AZ PHARMACY, LLC	DBA AMAZON PHARMACY #002	3809 E WATKINS ST	PHOENIX	AZ	85034	07/01/2019	01/17/2021
CH08126B	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/01/2023
CH081260E	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	01/01/2024
CH08126B	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/01/2023
CH081260E	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	01/01/2024
CH08126B	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/01/2023
CH081260E	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	01/01/2024
CH08126B	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/01/2023
CH081260E	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	01/01/2024
CH08126B	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/01/2023
CH081260E	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	01/01/2024
CH08126B	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/01/2023
CH081260E	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	01/01/2024
CH08126B	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/01/2023
CH081260E	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	01/01/2024
CH08126B	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/01/2023
CH081260E	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	01/01/2024
CH08126B	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/01/2023
CH081260E	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	01/01/2024
CH08126B	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/01/2023
CH081260E	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	01/01/2024
CH08126B	CITY MARKET PHARMACY	850 CASTLE VALLEY BLVD		NEW CASTLE	CO	81647	10/01/2015
CH08126B	CITY MARKET PHARMACY	2109 N FRONTAGE ROAD WEST		VAIL	CO	81657	04/01/2016	11/30/2023
CH081260E	CITY MARKET PHARMACY	850 CASTLE VALLEY BLVD		NEW CASTLE	CO	81647	10/01/2015
CH08126B	CITY MARKET PHARMACY #34	0103 MARKET STREET	PO BOX 3728	EAGLE	CO	81631-3278	10/01/2015
CH081260E	CITY MARKET PHARMACY #34	0103 MARKET STREET	PO BOX 3728	EAGLE	CO	81631-3278	10/01/2015
CH08126B	CITY MARKET PHARMACY #426	0072 BEAVER CREEK PLACE	P.O. BOX 5140	AVON	CO	81620	04/01/2016
CH081260E	CITY MARKET PHARMACY #426	0072 BEAVER CREEK PLACE	P.O. BOX 5140	AVON	CO	81620	01/01/2024
CH08126B	CITY MARKET PHARMACY #447	905 HIGHWAY 133		CARBONDALE	CO	81623	04/01/2016
CH081260E	CITY MARKET PHARMACY #447	905 HIGHWAY 133		CARBONDALE	CO	81623	01/01/2024
CH08126B	CITY MARKET STORE #443	PHARMACY DEPARTMENT	1320 RAILROAD AVENUE	RIFLE	CO	81650	10/01/2015
CH081260E	CITY MARKET STORE #443	PHARMACY DEPARTMENT	1320 RAILROAD AVENUE	RIFLE	CO	81650	10/01/2015
CH08126B	COMMUNITY MEDICAL CENTER PHARMACY	610 GATEWAY CENTER WAY	STE A - E	SAN DIEGO	CA	92102-4548	07/01/2017	03/29/2018
CH081260E	COMMUNITY MEDICAL CENTER PHARMACY	610 GATEWAY CENTER WAY	STE A - E	SAN DIEGO	CA	92102-4548	04/01/2017	06/01/2018
CH08126B	COMMUNITY MEDICAL CENTER PHARMACY	610 GATEWAY CENTER WAY	STE A - E	SAN DIEGO	CA	92102-4548	07/01/2018	01/17/2021
CH081260E	CURANT HEALTH FLORIDA, LLC	11001 ROOSEVELT BLVD N STE 1400		ST PETERSBURG	FL	33716	10/01/2015	03/18/2016
CH081260E	CURANT HEALTH GEORGIA LLC	CURANT HEALTH	200 TECHNOLOGY CT SE BLDG 200 SUITE B	SMYRNA	GA	30082-5250	10/01/2015	03/18/2016
CH08126B	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	04/01/2021
CH08126D	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	01/01/2024
CH081260E	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	01/01/2024
CH08126B	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	04/01/2021
CH081260E	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	01/01/2024
CH08126B	CVS PHARMACY, INC.	CVS PHARMACY # 17122	110 W MEADOWS DR	GLENWOOD SPRINGS	CO	81601	04/01/2021
CH081260E	CVS PHARMACY, INC.	CVS PHARMACY # 17122	110 W MEADOWS DR	GLENWOOD SPRINGS	CO	81601	01/01/2024
CH08126D	CVS PHARMACY, INC.	CVS PHARMACY # 17122	110 W MEADOWS DR	GLENWOOD SPRINGS	CO	81601	01/01/2024
CH08126B	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/01/2023
CH081260E	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	01/01/2024
CH08126D	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	04/01/2018	08/11/2021
CH08126B	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	04/01/2018	08/11/2021
CH08126D	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	04/01/2018	08/11/2021
CH081260E	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	04/01/2018	08/11/2021
CH08126F	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	04/01/2018	08/11/2021
CH08126G	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	04/01/2018	08/11/2021
CH08126D	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	04/01/2018
CH08126B	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	07/01/2024
CH08126B	DELIVERCARERX PHARMACY LLC	DELIVERCARERX PHARMACY LLC	1471 E BUSINESS CENTER DR STE 200	MT PROSPECT	IL	60056	07/01/2017	01/17/2021
CH081260E	DELIVERCARERX PHARMACY LLC	DELIVERCARERX PHARMACY LLC	1471 E BUSINESS CENTER DR STE 200	MT PROSPECT	IL	60056	04/01/2017	01/17/2021
CH08126B	DOWNTOWN DRUG	JASON GOTZINGER	825 GRAND AVE PO BOX 879	GLENWOOD SPRINGS	CO	81602	10/01/2024
CH08126B	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	07/01/2023
CH08126B	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	07/01/2023
CH08126B	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	07/01/2023
CH08126B	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	07/01/2023
CH08126B	M.N. PHARMACY LLC	DBA AMAZON PHARMACY #003	6701 NW 7TH ST., STE. #199	MIAMI	FL	33126	10/01/2018	04/01/2019
CH081260E	M.N. PHARMACY LLC	DBA AMAZON PHARMACY #003	6701 NW 7TH ST., STE. #199	MIAMI	FL	33126	07/01/2019	01/17/2021
CH08126B	OVERLAKE PHARMACY, LLC	4124 148TH AVE NE STE JA		REDMOND	WA	98052	04/01/2020	01/17/2021
CH08126B	PILLPACK LLC	DBA PILLPACK BY AMAZON PHARMACY	250 COMMERCIAL ST STE 2012	MANCHESTER	NH	03101	10/01/2018	04/01/2019
CH081260E	PILLPACK LLC	DBA PILLPACK BY AMAZON PHARMACY	250 COMMERCIAL ST STE 2012	MANCHESTER	NH	03101	07/01/2019	01/17/2021
CH08126G	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	04/01/2018	11/05/2021
CH08126F	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	04/01/2018	11/05/2021
CH08126D	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	04/01/2018	11/05/2021
CH08126B	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	04/01/2018	11/05/2021
CH081260E	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	04/01/2018	11/05/2021
CH08126B	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/01/2023
CH081260E	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	01/01/2024
CH08126B	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/01/2023
CH08126B	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	07/01/2023
CH08126B	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/01/2023
CH081260E	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	01/01/2024
CH081260E	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	01/01/2024
CH081260E	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	01/01/2024
CH08126B	SAFEWAY INC	SAFEWAY PHARMACY #0390	2425 MINER STREET PO BOX 70	IDAHO SPRINGS	CO	80452	10/01/2015	04/01/2019
CH08126B	SAFEWAY INC	SAFEWAY PHARMACY #1132	2001 GRAND AVE	GLENWOOD SPRINGS	CO	81601	10/01/2015	04/01/2019
CH081260E	SAFEWAY INC	SAFEWAY PHARMACY #1132	2001 GRAND AVE	GLENWOOD SPRINGS	CO	81601	07/01/2015	04/01/2019
CH081260E	THE KROGER CO., KS 113	1220 S. LIPAN STREET		DENVER	CO	80223	01/01/2020
CH08126B	THE KROGER CO., KS 113	1220 S. LIPAN STREET		DENVER	CO	80223	01/01/2020
CH08126B	THRIFTY PAYLESS INC.	RITE AID #6180	1412 GRAND AVENUE	GLENWOOD SPRINGS	CO	81601	10/01/2015	02/22/2018
CH081260E	THRIFTY PAYLESS INC.	RITE AID #6180	1412 GRAND AVENUE	GLENWOOD SPRINGS	CO	81601	07/01/2015	02/19/2018
CH08126B	TRUEPILL	3121 DIABLO AVE		HAYWARD	CA	94545	04/01/2020	01/17/2021
CH081260E	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/01/2021
CH08126B	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/01/2021
CH08126B	WAL-MART PHARMACY 10-1095	3010 BLAKE AVENUE		GLENWOOD SPRINGS	CO	81601	10/01/2015
CH081260E	WAL-MART PHARMACY 10-1095	3010 BLAKE AVENUE		GLENWOOD SPRINGS	CO	81601	07/01/2015
CH081260E	WAL-MART PHARMACY 10-1199	171 YODER AVE		AVON	CO	81620	01/01/2021
CH08126B	WAL-MART PHARMACY 10-1199	171 YODER AVE		AVON	CO	81620	01/01/2021
CH08126F	WAL-MART PHARMACY 10-1199	171 YODER AVE		AVON	CO	81620	01/01/2024
CH08126B	WAL-MART PHARMACY 10-5232	1000 AIRPORT RD		RIFLE	CO	81650	10/01/2015
CH081260E	WAL-MART PHARMACY 10-5232	1000 AIRPORT RD		RIFLE	CO	81650	07/01/2015
CH081260E	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/01/2021
CH08126B	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/01/2021
CH08126D	WALGREEN CO.	DBA: WALGREENS #15101	15 SUN ROAD P.O. BOX 8438	AVON	CO	81620	04/01/2018
CH08126D	WALGREEN CO.	WALGREENS #18163	1412 GRAND AVE	GLENWOOD SPRINGS	CO	81601	04/01/2018
CH08126F	WALGREEN CO.	WALGREENS #18163	1412 GRAND AVE	GLENWOOD SPRINGS	CO	81601	04/01/2018
CH08126F	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #21454	4745 ARAPAHOE AVE STE 140	BOULDER	CO	80303	04/01/2018
CH08126G	WALGREEN CO.	WALGREENS #18163	1412 GRAND AVE	GLENWOOD SPRINGS	CO	81601	04/01/2018
CH08126B	WALGREEN CO.	WALGREENS #18163	1412 GRAND AVE	GLENWOOD SPRINGS	CO	81601	03/08/2018
CH08126D	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #21454	4745 ARAPAHOE AVE STE 140	BOULDER	CO	80303	04/01/2018
CH081260E	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #21454	4745 ARAPAHOE AVE STE 140	BOULDER	CO	80303	04/01/2018
CH08126B	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #21454	4745 ARAPAHOE AVE STE 140	BOULDER	CO	80303	04/01/2018
CH08126B	WALGREEN CO.	DBA: WALGREENS #15101	15 SUN ROAD P.O. BOX 8438	AVON	CO	81620	04/01/2018
CH08126G	WALGREEN CO.	DBA: WALGREENS #15101	15 SUN ROAD P.O. BOX 8438	AVON	CO	81620	04/01/2018
CH081260E	WALGREEN CO.	WALGREENS #18163	1412 GRAND AVE	GLENWOOD SPRINGS	CO	81601	04/01/2018
CH08126G	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #21454	4745 ARAPAHOE AVE STE 140	BOULDER	CO	80303	04/01/2018
CH081260E	WALGREEN CO.	DBA: WALGREENS #15101	15 SUN ROAD P.O. BOX 8438	AVON	CO	81620	04/01/2018
CH08126F	WALGREEN CO.	DBA: WALGREENS #15101	15 SUN ROAD P.O. BOX 8438	AVON	CO	81620	04/01/2018
CH08126B	Walgreens #21397	Walgreens Central Fill #21397	5675 Pecos St. Suite 100	Denver	CO	80221-6655	04/01/2023
CH081260E	Walgreens #21397	Walgreens Central Fill #21397	5675 Pecos St. Suite 100	Denver	CO	80221-6655	01/01/2024
CH08126B	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/01/2018	08/11/2021
CH081260E	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/01/2018	08/11/2021
CH081260E	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/01/2018	08/11/2021
CH08126G	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/01/2018	08/11/2021
CH08126B	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	04/01/2018	11/05/2021
CH08126F	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/01/2018	08/11/2021
CH081260E	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/01/2018	08/11/2021
CH08126B	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/01/2018	08/11/2021
CH08126D	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	04/01/2018	11/05/2021
CH081260E	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	04/01/2018	11/05/2021
CH08126D	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/01/2018	08/11/2021
CH08126G	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/01/2018	08/11/2021
CH08126D	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/01/2018	08/11/2021
CH08126G	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/01/2018	08/11/2021
CH08126D	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/01/2018	08/11/2021
CH08126B	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/01/2018	08/11/2021
CH08126F	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/01/2018	08/11/2021
CH08126G	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	04/01/2018	11/05/2021
CH08126F	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	04/01/2018	11/05/2021
CH08126F	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/01/2018	08/11/2021
CH08126B	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	07/01/2024
CH08126B	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	07/01/2024
CH08126B	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/01/2024
CH08126B	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	01/01/2024
CH08126B	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	04/01/2024
CH08126B	WESTERN PHARMACY GROUP LLC	DBA COMMUNITY MEDICAL CENTER PHARMACY	610 GATEWAY CENTER WAY SUITES A--E	SAN DIEGO	CA	92102	07/01/2018	01/17/2021
CH08126F	WESTERN PHARMACY GROUP LLC	DBA COMMUNITY MEDICAL CENTER PHARMACY	610 GATEWAY CENTER WAY SUITES A--E	SAN DIEGO	CA	92102	07/01/2018	08/11/2021
CH08126D	WESTERN PHARMACY GROUP LLC	DBA COMMUNITY MEDICAL CENTER PHARMACY	610 GATEWAY CENTER WAY SUITES A--E	SAN DIEGO	CA	92102	07/01/2018
CH081260E	WESTERN PHARMACY GROUP LLC	DBA COMMUNITY MEDICAL CENTER PHARMACY	610 GATEWAY CENTER WAY SUITES A--E	SAN DIEGO	CA	92102	07/01/2018	01/17/2021
CH08126G	WESTERN PHARMACY GROUP LLC	DBA COMMUNITY MEDICAL CENTER PHARMACY	610 GATEWAY CENTER WAY SUITES A--E	SAN DIEGO	CA	92102	07/01/2018	08/11/2021

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	2/7/2024 1:03:27 PM	2/11/2025 9:40:43 AM	2/11/2025 9:40 AM
Contacts	Authorizing Official	Update	Group Change Request	Franta, Annette M CFO Mountain Family Health Centers 9709281636	Fernandez, Art M Chief Operating Officer Mountain Family Health Centers 9709452840-7205	4/26/2024 9:35 AM
Contacts	Primary Contact	Update	Group Change Request	Illias, Rachel Pharmacy Director Mountain Family Health Centers 9709452840-7230	Kendall, Shiela Provider Relations and Credentialing Manager Mountain Family Health Centers 9709452840-7369	4/26/2024 9:35 AM
Addresses	Billing Address	Update	Group Change Request	Mountain Family Health PO Box 339 Glenwood Springs, CO 81601	Mountain Family Health Centers PO Box 339 Glenwood Springs, CO 81602	4/24/2024 5:11 PM
Details	Last Recertification Date	Update	Recertification	2/1/2023 12:24:16 PM	2/7/2024 1:03:27 PM	2/7/2024 1:03 PM
Details	Entity Subname	Update	Recertification	MOUNTAIN FAMILY HEALTH CENTERS Roaring Fork High School SBHC	Mountain Family Health Centers Roaring Fork High School SBHC	2/7/2024 1:03 PM
Contacts	Authorizing Official	Update	Group Change Request	Brooks, Ross CEO Mountain Family Health Centers 9709452840	Franta, Annette M CFO Mountain Family Health Centers 9709281636	6/16/2023 1:20 PM
Contacts	Authorizing Official	Update	Change Request	Illias, Rachel Pharmacy Director Mountain Family Health Centers 9709452840-7230	Brooks, Ross CEO Mountain Family Health Centers 9709452840	5/26/2023 9:53 AM
Contacts	Primary Contact	Update	Change Request	Marshall, Jackie Marie Compliance Coordinator Mountain Family Health Centers 9709452840-7212	Illias, Rachel Pharmacy Director Mountain Family Health Centers 9709452840-7230	5/26/2023 9:53 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	05600812 (CO)		2/1/2023 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/1/2023 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		9000186600	2/1/2023 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CO	2/1/2023 12:24 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1477552388 (CO)		2/1/2023 12:24 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1568073229	2/1/2023 12:24 PM
Medicaid Billing	NPI: State	Insert	Recertification		CO	2/1/2023 12:24 PM
Details	Last Recertification Date	Update	Recertification	2/11/2022 12:03:46 PM	2/1/2023 12:24:16 PM	2/1/2023 12:24 PM
Contacts	Authorizing Official	Update	New Registration	Illias, Rachel Pharmacy Director Mountain Family Health Centers 9709452840	Illias, Rachel Pharmacy Director Mountain Family Health Centers 9709452840-7230	1/17/2023 7:53 PM
Contacts	Authorizing Official	Update	Group Change Request	Fernandez, Art M Chief Operating Officer Mountain Family Health Centers 9709452840-7205	Illias, Rachel Pharmacy Director Mountain Family Health Centers 9709452840	3/21/2022 12:33 PM
Details	Last Recertification Date	Update	Recertification		2/11/2022 12:03:46 PM	2/11/2022 12:03 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/5/2021 2:39 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		05600812	4/5/2021 2:39 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	4/5/2021 2:39 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1477552388	4/5/2021 2:39 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	4/5/2021 2:39 PM
Details	State	Update		Approved	Active	4/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Fernandez, Art M Chief Operating Officer Mountain Family Health Centers 9709452840-7205	1/11/2021 1:35 PM
Details	340B ID	Update	New Registration		CH08126J	1/11/2021 1:35 PM
Dates	Participating Approval Date	Update	New Registration		1/11/2021 1:35:01 PM	1/11/2021 1:35 PM
Details	State	Update	New Registration	Pending	Approved	1/11/2021 1:35 PM
Dates	Signed By Date	Update	New Registration		1/7/2021 2:54:01 PM	1/11/2021 1:35 PM
Dates	Start Date	Update	New Registration		4/1/2021 12:00:00 AM	1/11/2021 1:35 PM
Addresses	Main Address	Insert	New Registration		2270 Highway 133 Rm 14 Carbondale, CO 81623-9271	1/7/2021 1:44 PM
Addresses	Billing Address	Insert	New Registration		Mountain Family Health PO Box 339 Glenwood Springs, CO 81601	1/7/2021 1:44 PM
Contacts	Primary Contact	Insert	New Registration		Marshall, Jackie Marie Compliance Coordinator Mountain Family Health Centers 9709452840-7212	1/7/2021 1:44 PM
Contacts	Authorizing Official	Insert	New Registration		Fernandez, Art M Chief Operating Officer Mountain Family Health Centers 9709452840-7205	1/7/2021 1:44 PM
Details	Assistance Received From Date	Insert	New Registration			1/7/2021 1:44 PM
Details	Assistance Received To Date	Insert	New Registration			1/7/2021 1:44 PM
Details	Last Recertification Date	Insert	New Registration			1/7/2021 1:44 PM
Details	Grant Number	Insert	New Registration		H80CS00830	1/7/2021 1:44 PM
Details	340B ID	Insert	New Registration			1/7/2021 1:44 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/7/2021 1:44 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/7/2021 1:44 PM
Details	Medicare Provider Number	Insert	New Registration			1/7/2021 1:44 PM
Details	Entity Name	Insert	New Registration		Mountain Family Health Centers	1/7/2021 1:44 PM
Details	NOFO Number	Insert	New Registration			1/7/2021 1:44 PM
Details	Program Code	Insert	New Registration		CH	1/7/2021 1:44 PM
Details	Entity Subname	Insert	New Registration		MOUNTAIN FAMILY HEALTH CENTERS Roaring Fork High School SBHC	1/7/2021 1:44 PM
Dates	Participating Approval Date	Insert	New Registration			1/7/2021 1:44 PM
Details	State	Insert	New Registration		Pending	1/7/2021 1:44 PM
Dates	Registration Date	Insert	New Registration		1/7/2021 1:44:46 PM	1/7/2021 1:44 PM
Dates	Signed By Date	Insert	New Registration			1/7/2021 1:44 PM
Dates	Start Date	Insert	New Registration			1/7/2021 1:44 PM
Terminations	Termination Comments	Insert	New Registration			1/7/2021 1:44 PM
Terminations	Termination Date	Insert	New Registration			1/7/2021 1:44 PM
Terminations	Termination Effective Date	Insert	New Registration			1/7/2021 1:44 PM
Terminations	Termination Reason	Insert	New Registration			1/7/2021 1:44 PM

340B Drug Pricing Program Database