Covered Entity Details

CH091037X St. John's Well Child And Family Center, Inc. (Active) - information as of 6/3/2025 11:59:19 AM

Main Details

Name

St. John's Well Child And Family Center, Inc.

Subdivision Name

SJWCFC - Avalon Health and Access Center

Type

HRSA-Funded Health Center

Site ID

BPS-H80-031812

340B ID

CH091037X

Grant Number

H80CS00873

Additional Details

Current Program Status

Active

Registration Date

4/14/2021

Participating Start Date

7/1/2021

Participating Approval Date

4/15/2021

Last Recertification Date

2/10/2025

Contacts

Authorizing Official

St. John's Community Health
James Mangia, CEO
(323) 541-1600 Ext: 4000

Primary Contact

St. John Community Center
Peter Nabil Tawfik, Chief of Pharmacy Officer
(615) 957-8115

Addresses

Street Address

6818 Avalon Blvd
Los Angeles, CA 90003-1922

Billing Address

St. John's Well Child and Family Center
808 W. 58th St.
Los Angeles, CA 90037

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	1285874826	1285874826,1811369697,1821841727,1356194252

Shipping Addresses

Shipping Address 1

St. John's Well Child and Family Center
808 W. 58th St.
Los Angeles, CA 90037

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	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	07/07/2021	10/01/2021		04/03/2023	12/29/2023
Contract Detail	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	07/07/2021	10/01/2021		04/03/2023	12/29/2023

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	Address Cont.	City	State
CH0910370	Active	BPS-H80-008081	ST. JOHN'S WELL CHILD AND FAMILY CENTER, INC.	St. Johns Well Child and Family Center Magnolia Place	1910 Magnolia Ave		Los Angeles	CA
CH091037A	Active	BPS-H80-003589	ST. JOHN'S COMMUNITY HEALTH	SJCH COMPTON CLINIC	2115 N Wilmington Ave		Compton	CA
CH091037AA	Active	BPS-H80-036058	ST. JOHN'S COMMUNITY HEALTH	Mendez High School Health and Wellness Center	1321 E 1st St		Los Angeles	CA
CH091037AB	Active	BPS-H80-036818	ST. JOHN'S COMMUNITY HEALTH	SJCH Health Center at the Jaqueline Avant Children and Family Center	1741 E 120th St		Los Angeles	CA
CH091037AC	Active	BPS-H80-036999	ST. JOHN'S COMMUNITY HEALTH	SJCH - Roosevelt High School-Based Health Center	444 S Mathews St		Los Angeles	CA
CH091037AD	Active	BPS-H80-037881	ST. JOHN'S COMMUNITY HEALTH	SJCH San Bernardino Health Center	1500 N Waterman Ave		San Bernardino	CA
CH091037AE	Active	BPS-H80-038400	ST. JOHN'S COMMUNITY HEALTH	SJCH San Jacinto Health Center	1821 S. San Jacinto St. UNIT D		San Jacinto	CA
CH091037AF	Active	BPS-H80-038128	ST. JOHN'S COMMUNITY HEALTH	SJCH Mobile #4	808 W 58th St		Los Angeles	CA
CH091037AG	Active	BPS-H80-039167	ST. JOHN'S COMMUNITY HEALTH	SJCH Indio Health Center	82025 Highway 111 UNIT 101		Indio	CA
CH091037AH	Approved	BPS-H80-039848	ST. JOHN'S COMMUNITY HEALTH	SJCH - Mobile 5	808 W 58th St		Los Angeles	CA
CH091037B	Active	BPS-H80-005389	ST. JOHN'S WELL CHILD AND FAMILY CENTER, INC.	ABRAHAM LINCOLN SBHC	2512 Alta St		Los Angeles	CA
CH091037D	Active	BPS-H80-002637	ST. JOHN'S WELL CHILD AND FAMILY CENTER, INC.	SJWCFC LEWIS FRAYSER CLINIC	5701 S. Hoover St		Los Angeles	CA
CH091037G	Active	BPS-H80-009393	ST. JOHN'S WELL CHILD AND FAMILY CENTER, INC.	St. John's Well Child and Family Center Hyde Park School Based Health Center	6505 8th Avenue		Los Angeles	CA
CH091037H	Active	BPS-H80-008858	ST. JOHN'S WELL CHILD AND FAMILY CENTER, INC.	SJWCFC Dominguez High School Based Health Center	15301 S San Jose Ave		Compton	CA
CH091037J	Active	BPS-H80-010744	ST. JOHN'S WELL CHILD AND FAMILY CENTER, INC.	St. John's Well Child and Family Center East Compton Community Health Center	15715 S. Atlantic Ave.	FL 2	Compton	CA
CH091037K	Active	BPS-H80-010069	ST. JOHN'S COMMUNITY HEALTH	SJCH S. Mark Taper Foundation Chronic Disease and Environmental Health Center	808 W 58th St		Los Angeles	CA
CH091037M	Active	BPS-H80-013173	ST. JOHN'S WELL CHILD AND FAMILY CENTER, INC.	SJWCFC Washington High School	1555 W 110th St		Los Angeles	CA
CH091037N	Active	BPS-H80-013318	ST. JOHN'S WELL CHILD AND FAMILY CENTER, INC.	SJCH Mobile #2	1555 W 110th St		Los Angeles	CA
CH091037P	Active	BPS-H80-013482	ST. JOHN'S WELL CHILD AND FAMILY CENTER, INC.	SJWCFC Mobile #1	808 W. 58th St.		Los Angeles	CA
CH091037Q	Active	BPS-H80-013874	ST. JOHN'S WELL CHILD AND FAMILY CENTER, INC.	SJWCFC Manual Arts High School-based Clinic	4085 S Vermont Ave		Los Angeles	CA
CH091037R	Active	BPS-H80-013748	ST. JOHN'S WELL CHILD AND FAMILY CENTER, INC.	Leavey Community Clinic	3628 E. Imperial Hwy, Suite 301		Lynwood	CA
CH091037S	Active	BPS-H80-014983	ST. JOHN'S COMMUNITY HEALTH	SJCH Traynham Health Center	326 W. 23rd Street		Los Angeles	CA
CH091037T	Active	BPS-H80-021140	St. John's Well Child And Family Center, Inc.	SJWCFC Crenshaw Health Center	4251 Crenshaw Blvd		Los Angeles	CA
CH091037U	Terminated	BPS-H80-017666	St. John's Well Child And Family Center, Inc.	SJWCFC L.A. Trade Technical College Health Center	400 W. Washington Blvd. MA-107		Los Angeles	CA
CH091037V	Active	BPS-H80-029840	St. John's Well Child And Family Center, Inc.	SJWCFC Rolland Curtis Gardens Health Center	1060 Exposition Blvd		Los Angeles	CA
CH091037W	Active	BPS-H80-027334	St. John's Well Child And Family Center, Inc.	SJWCFC at Compton College	1111 E Artesia Blvd		Compton	CA
CH091037X	Active	BPS-H80-031812	St. John's Well Child And Family Center, Inc.	SJWCFC - Avalon Health and Access Center	6818 Avalon Blvd		Los Angeles	CA
CH091037Y	Active	BPS-H80-032561	St. John's Well Child And Family Center, Inc.	SJWCFC - Mobile 3	808 W 58th St		Los Angeles	CA
CH091037Z	Active	BPS-H80-021577	St. John's Well Child And Family Center, Inc.	SJWCFC 50th Street Dental Clinic at Boys & Girls Club	1000 W 50th St		Los Angeles	CA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH0910370	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	01/01/2025
CH0910370	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	01/01/2025
CH0910370	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	01/01/2025
CH0910370	COMPTON COMMUNITY PHARMACY	555 W COMPTON BLVD STE 102		COMPTON	CA	90220-3087	09/19/2012	12/31/2015
CH091037A	COMPTON COMMUNITY PHARMACY	555 W COMPTON BLVD STE 102		COMPTON	CA	90220-3087	01/06/2011	12/31/2015
CH0910370	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	04/01/2016	04/03/2023
CH091037A	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	04/01/2016	04/03/2023
CH091037D	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	04/01/2016	04/03/2023
CH091037G	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	04/01/2016	04/03/2023
CH091037B	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	04/01/2016	04/03/2023
CH091037J	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	04/01/2016	04/03/2023
CH091037H	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	04/01/2016	04/03/2023
CH091037K	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	10/01/2015	04/03/2023
CH091037M	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	04/01/2016	04/03/2023
CH091037R	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	01/01/2017	04/03/2023
CH091037Q	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	04/01/2016	04/03/2023
CH091037S	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	04/01/2016	04/03/2023
CH091037P	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	04/01/2018	04/03/2023
CH091037N	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	04/01/2018	04/03/2023
CH091037T	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	04/01/2018	04/03/2023
CH091037V	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	07/01/2020	04/03/2023
CH091037X	COUNTY OF LOS ANGELES - AUDITOR CONTROLL	313 N FIGUEROA ST STE 1225	HEALTH SERVICES CENTRAL PHARMACY	LOS ANGELES	CA	90012-2602	10/01/2021	04/03/2023
CH0910370	CVS PHARMACY, INC.	DBA CVS/PHARMACY #10909	6474 E. NORTHWEST HWY	DALLAS	TX	75214	07/01/2023	07/22/2024
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09665	5944 N FIGUEROA ST	LOS ANGELES	CA	90042	07/01/2023	07/22/2024
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09666	2419 WORKMAN STREET	LOS ANGELES	CA	90031	07/01/2023
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #4019	5837 S. CENTRAL AVE.	LOS ANGELES	CA	90001	07/01/2023
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09578	3120 W. IMPERIAL HWY.	INGLEWOOD	CA	90303	07/01/2023
CH0910370	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17349	1621 S ALAMEDA ST	COMPTON	CA	90220	07/01/2023	07/22/2024
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09507	650 EAST EL SEGUNDO BOULEVARD	LOS ANGELES	CA	90059	07/01/2023
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09594	901 S. CENTRAL AVENUE	COMPTON	CA	90220	07/01/2023	07/22/2024
CH0910370	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY #10663	1919 SOUTH HOOVER STREET	LOS ANGELES	CA	90007	07/01/2023
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09626	1701 SOUTH WESTERN AVENUE	LOS ANGELES	CA	90006	07/01/2023
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08870	8859 ALONDRA BLVD.	PARAMOUNT	CA	90723	07/01/2023	07/22/2024
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08853	1645 EAST 103RD STREET	LOS ANGELES	CA	90002	07/01/2023
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08858	7101 ATLANTIC AVENUE	BELL	CA	90201	07/01/2023
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08892	5822 SOUTH VERMONT AVENUE	LOS ANGELES	CA	90044	07/01/2023
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09566	596 LONG BEACH BOULEVARD	LONG BEACH	CA	90802	07/01/2023
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09660	3751 WILSHIRE BOULEVARD	LOS ANGELES	CA	90010	07/01/2023
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08898	7300 S ALAMEDA ST	WALNUT PARK	CA	90255	07/01/2023
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09495	220 EAST COMPTON BOULEVARD	COMPTON	CA	90220	07/01/2023
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08835	3710 TWEEDY BOULEVARD	SOUTH GATE	CA	90280	07/01/2023
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09732	861 NORTH VINE STREET	HOLLYWOOD	CA	90038	07/01/2023	07/22/2024
CH0910370	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17481	6750 CHERRY AVE	LONG BEACH	CA	90805	07/01/2023	07/22/2024
CH0910370	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY #10292	4030 SOUTH WESTERN AVE.	LOS ANGELES	CA	90062	07/01/2023
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10915	1025 E. ADAMS BLVD., 1ST FLOOR	LOS ANGELES	CA	90011	07/01/2023
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09582	3741 CRENSHAW BOULEVARD	LOS ANGELES	CA	90016	07/01/2023
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY # 2396	3335 S. FIGUEROA ST., UNIT Q	LOS ANGELES	CA	90007	07/01/2023
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09123	3800 MARTIN LUTHER KING JR. BOULEVARD	LYNWOOD	CA	90262	07/01/2023
CH0910370	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09580	5101 OBAMA BLVD	LOS ANGELES	CA	90016	07/01/2023	03/05/2025
CH0910370	MORNINGSIDE MEDICAL PHARMACY INC	MORNINGSIDE MEDICAL PHARMACY	1704 W. MANCHESTER AVE,	LOS ANGELES	CA	90047	09/19/2012	12/31/2015
CH091037D	MORNINGSIDE MEDICAL PHARMACY INC	MORNINGSIDE MEDICAL PHARMACY	1704 W. MANCHESTER AVE,	LOS ANGELES	CA	90047	01/11/2011	12/31/2015
CH0910370	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/01/2025
CH0910370	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY	8607 SANTA MONICA BOULEVARD	WEST HOLLYWOOD	CA	90069	07/01/2025
CH0910370	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	04/01/2016	04/03/2023
CH091037A	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	04/01/2016	04/03/2023
CH091037D	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	04/01/2016	04/03/2023
CH091037G	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	04/01/2016	04/03/2023
CH091037B	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	04/01/2016	04/03/2023
CH091037J	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	04/01/2016	04/03/2023
CH091037H	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	04/01/2016	04/03/2023
CH091037K	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	04/01/2016	04/03/2023
CH091037M	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	04/01/2016	04/03/2023
CH091037R	RX E-FILL SOLUTIONS	28341 CONSTELLATION RD		SANTA CLARITA	CA	91355	01/01/2017	04/03/2023
CH091037Q	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	04/01/2016	04/03/2023
CH091037S	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	04/01/2016	04/03/2023
CH091037T	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	04/01/2018	04/03/2023
CH091037N	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	04/01/2018	04/03/2023
CH091037P	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	04/01/2018	04/03/2023
CH091037V	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	07/01/2020	04/03/2023
CH091037X	RX E-FILL SOLUTIONS	CARDINAL HEALTH PHARMACY SERVICES, LLC	27680 AVENUE MENTRY STE 100	VALENCIA	CA	91355	10/01/2021	04/03/2023
CH0910370	SOUTH FIGUEROA DRUGS		1503 W. MARTIN LUTHER KING JR BLVD	LOS ANGELES	CA	90062	10/22/2012	12/15/2015
CH091037D	SOUTH FIGUEROA DRUGS		1503 W. MARTIN LUTHER KING JR BLVD	LOS ANGELES	CA	90062	01/11/2011	12/31/2015
CH0910370	THRIFTY PAYLESS, INC.	RITE AID #6255	1038 EAST COLORADO BOULEVARD	PASADENA	CA	91106	07/01/2023
CH0910370	THRIFTY PAYLESS, INC.	RITE AID #5445	4322 SOUTH FIGUEROA STREET	LOS ANGELES	CA	90037	07/01/2023
CH0910370	THRIFTY PAYLESS, INC.	RITE AID #5426	1815 SOUTH VERMONT AVENUE	LOS ANGELES	CA	90006	07/01/2023
CH0910370	THRIFTY PAYLESS, INC.	RITE AID #5455	11750 WILMINGTON AVENUE	LOS ANGELES	CA	90059	07/01/2023
CH0910370	THRIFTY PAYLESS, INC.	RITE AID #5479	4410 EAST SLAUSON AVENUE	MAYWOOD	CA	90270	07/01/2023
CH0910370	THRIFTY PAYLESS, INC.	RITE AID #6313	107 SOUTH LONG BEACH BLVD	COMPTON	CA	90221	07/01/2023
CH0910370	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/01/2023
CH0910370	WAL-MART PHARMACY 10-2110	14501 LAKEWOOD BLVD		PARAMOUNT	CA	90723	07/01/2023
CH0910370	WAL-MART PHARMACY 10-2842	1290 EAST ONTARIO AVENUE		CORONA (S)	CA	92881	07/01/2023
CH0910370	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/01/2023
CH0910370	WALMART PHARMACY #10-5807	WALMART STORES INC	2100 NORTH LONG BEACH BOULEVARD	COMPTON	CA	90221-7271	07/01/2023	07/22/2024
CH0910370	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	07/01/2023
CH0910370	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	2/6/2024 7:34:57 PM	2/10/2025 6:22:01 PM	2/10/2025 6:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1821841727	1/17/2025 1:44 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	1/17/2025 1:44 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1356194252	1/17/2025 1:44 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	1/17/2025 1:44 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1811369697	9/3/2024 5:31 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	9/3/2024 5:31 PM
Details	Last Recertification Date	Update	Recertification	2/1/2023 7:52:20 AM	2/6/2024 7:34:57 PM	2/6/2024 7:34 PM
Contacts	Authorizing Official	Update	Profile Change Request	Mangia, James CEO St. John's Well Child and Family Center 3235411600-4000	Mangia, James CEO St. John's Community Health 3235411600-4000	1/5/2024 12:43 PM
Contacts	Signed By	Update	Profile Change Request	Mangia, James CEO St. John's Well Child and Family Center 3235411600-4000	Mangia, James CEO St. John's Community Health 3235411600-4000	1/5/2024 12:43 PM
Addresses	Billing Address	Insert	Recertification		St. John's Well Child and Family Center 808 W. 58th St. Los Angeles, CA 90037	2/1/2023 7:52 AM
Addresses	Shipping Address	Insert	Recertification		St. John's Well Child and Family Center 808 W. 58th St. Los Angeles, CA 90037	2/1/2023 7:52 AM
Details	Last Recertification Date	Update	Recertification	2/3/2022 2:33:36 PM	2/1/2023 7:52:20 AM	2/1/2023 7:52 AM
Contacts	Primary Contact	Update	Group Change Request	Clemente, Mario Director of Institutional Giving St. John's Well Child and Family Center 3233828611	Tawfik, Peter Nabil Chief of Pharmacy Officer St. John Community Center 6159578115	9/28/2022 6:15 AM
Contacts	Primary Contact	Update	Group Change Request	Barahona, Ernesto Chief Development Officer St. John's Well Child and Family Center 3235411600-1115	Clemente, Mario Director of Institutional Giving St. John's Well Child and Family Center 3233828611	7/13/2022 9:38 AM
Details	Last Recertification Date	Update	Recertification		2/3/2022 2:33:36 PM	2/3/2022 2:33 PM
Contacts	Primary Contact	Update	Change Request	Elabiad, Ebba Senior Director of Pharmacy St. John's Well Child & Family Center 3235411600-1346	Barahona, Ernesto Chief Development Officer St. John's Well Child and Family Center 3235411600-1115	10/26/2021 8:07 AM
Details	State	Update		Approved	Active	7/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Mangia, James CEO St. John's Well Child and Family Center 3235411600-4000	4/15/2021 2:14 PM
Details	340B ID	Update	New Registration		CH091037X	4/15/2021 2:14 PM
Dates	Participating Approval Date	Update	New Registration		4/15/2021 2:14:04 PM	4/15/2021 2:14 PM
Details	State	Update	New Registration	Pending	Approved	4/15/2021 2:14 PM
Dates	Signed By Date	Update	New Registration		4/14/2021 3:12:44 PM	4/15/2021 2:14 PM
Dates	Start Date	Update	New Registration		7/1/2021 12:00:00 AM	4/15/2021 2:14 PM
Addresses	Main Address	Insert	New Registration		6818 Avalon Blvd Los Angeles, CA 90003-1922	4/14/2021 3:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/14/2021 3:12 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1285874826	4/14/2021 3:12 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/14/2021 3:12 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1285874826	4/14/2021 3:12 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/14/2021 3:12 PM
Contacts	Authorizing Official	Insert	New Registration		Mangia, James CEO St. John's Well Child and Family Center 3235411600-4000	4/14/2021 3:12 PM
Contacts	Primary Contact	Insert	New Registration		Elabiad, Ebba Senior Director of Pharmacy St. John's Well Child & Family Center 3235411600-1346	4/14/2021 3:12 PM
Details	Assistance Received From Date	Insert	New Registration			4/14/2021 3:12 PM
Details	Assistance Received To Date	Insert	New Registration			4/14/2021 3:12 PM
Details	Last Recertification Date	Insert	New Registration			4/14/2021 3:12 PM
Details	Grant Number	Insert	New Registration		H80CS00873	4/14/2021 3:12 PM
Details	340B ID	Insert	New Registration			4/14/2021 3:12 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/14/2021 3:12 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/14/2021 3:12 PM
Details	Medicare Provider Number	Insert	New Registration			4/14/2021 3:12 PM
Details	Entity Name	Insert	New Registration		St. John's Well Child And Family Center, Inc.	4/14/2021 3:12 PM
Details	NOFO Number	Insert	New Registration			4/14/2021 3:12 PM
Details	Program Code	Insert	New Registration		CH	4/14/2021 3:12 PM
Details	Entity Subname	Insert	New Registration		SJWCFC - Avalon Health and Access Center	4/14/2021 3:12 PM
Dates	Participating Approval Date	Insert	New Registration			4/14/2021 3:12 PM
Details	State	Insert	New Registration		Pending	4/14/2021 3:12 PM
Dates	Registration Date	Insert	New Registration		4/14/2021 3:12:41 PM	4/14/2021 3:12 PM
Dates	Signed By Date	Insert	New Registration			4/14/2021 3:12 PM
Dates	Start Date	Insert	New Registration			4/14/2021 3:12 PM
Terminations	Termination Comments	Insert	New Registration			4/14/2021 3:12 PM
Terminations	Termination Date	Insert	New Registration			4/14/2021 3:12 PM
Terminations	Termination Effective Date	Insert	New Registration			4/14/2021 3:12 PM
Terminations	Termination Reason	Insert	New Registration			4/14/2021 3:12 PM

340B Drug Pricing Program Database