Covered Entity Details

CHC28956-04 Valle Del Sol, Inc. (Active) - information as of 5/14/2025 10:57:35 PM

Main Details

Name

Valle Del Sol, Inc.

Subdivision Name

Valle del Sol_ Maryvale_8410

Type

HRSA-Funded Health Center

Site ID

BPS-H80-029847

340B ID

CHC28956-04

Grant Number

H80CS28956

Additional Details

Current Program Status

Active

Registration Date

10/13/2021

Participating Start Date

1/1/2022

Participating Approval Date

11/1/2021

Last Recertification Date

2/17/2025

Contacts

Authorizing Official

Valle Del Sol
Mike Renaud, President & Chief Executive Officer
(602) 258-6797 Ext: 1320

Primary Contact

Valle Del Sol
Rebecca Zelaya, Pharmacy Director
(602) 258-6797 Ext: 6213

Addresses

Street Address

8410 W Thomas Rd
Ste 116
Phoenix, AZ 85037-3356

Billing Address

Valle del Sol, Inc.
3877 N 7th St
Suite 400
Phoenix, AZ 85014

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
AZ	598798,801237,871351	1659927556,1336480037,1750712766

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	GENOA HEALTHCARE LLC	460 NORTH MESA DR STE 201	SUITE 201P	MESA	AZ	85201	11/01/2021	01/01/2022		01/01/2022
Contract Detail	GENOA HEALTHCARE LLC	3807 N 7TH ST STE P		PHOENIX	AZ	85014	11/01/2021	01/01/2022		01/01/2022
Contract Detail	GENOA HEALTHCARE LLC	1209 S 1ST AVE		PHOENIX	AZ	85003	11/01/2021	01/01/2022		01/01/2022
Contract Detail	GENOA HEALTHCARE, LLC	1705 W MAIN ST		MESA	AZ	85201-6920	11/01/2021	01/01/2022	04/17/2023	04/17/2023

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CHC28956-00	Active	BPS-H80-015754	Valle Del Sol, Inc.	Valle del Sol_3807	3807 N 7th St	Phoenix	AZ
CHC28956-01	Active	BPS-H80-019756	Valle Del Sol, Inc.	Valle del Sol_502	502 N 27th Ave	Phoenix	AZ
CHC28956-02	Active	BPS-H80-017738	Valle Del Sol, Inc.	Valle del Sol_Red Mountain Service Center_1209	1209 S 1st Ave	Phoenix	AZ
CHC28956-03	Active	BPS-H80-032650	Valle Del Sol, Inc.	Valle del Sol Mobile Van	3807 N 7th St	Phoenix	AZ
CHC28956-04	Active	BPS-H80-029847	Valle Del Sol, Inc.	Valle del Sol_ Maryvale_8410	8410 W Thomas Rd	Phoenix	AZ
CHC28956-05	Active	BPS-H80-022149	Valle Del Sol, Inc.	Valle del Sol_Mesa_334	334 W 10th Pl	Mesa	AZ
CHC28956-06	Terminated	BPS-H80-032649	Valle Del Sol, Inc.	Valle del Sol_4117	4117 N 17th St	Phoenix	AZ
CHC28956-07	Active	BPS-H80-032833	Valle Del Sol, Inc.	Valle del Sol_4135	4135 S Power Rd	Mesa	AZ
CHC28956-08	Active	BPS-H80-034754	Valle del Sol, Inc.	Valle del Sol Mobile Unit 2	3807 N 7th St	Phoenix	AZ

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CHC28956-00	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	07/01/2024
CHC28956-00	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03383	7550 SOUTH 19TH AVE.	PHOENIX	AZ	85041	04/01/2023
CHC28956-00	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09213	305 E. BROWN RD.	MESA	AZ	85201	04/01/2023
CHC28956-01	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03383	7550 SOUTH 19TH AVE.	PHOENIX	AZ	85041	07/01/2024
CHC28956-00	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	04/01/2023
CHC28956-00	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/01/2023
CHC28956-00	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/01/2023
CHC28956-00	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	04/01/2023
CHC28956-00	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	04/01/2023
CHC28956-00	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/01/2023
CHC28956-00	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	04/01/2023
CHC28956-00	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/01/2023
CHC28956-00	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/01/2023
CHC28956-00	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	04/01/2023
CHC28956-00	CVS 3268 GILBERT, L.L.C.	DBA: CVS/PHARMACY # 03268	765 S. LINDSAY RD.	GILBERT	AZ	85296	04/01/2023
CHC28956-00	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	04/01/2023
CHC28956-00	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	04/01/2023
CHC28956-00	CVS GILBERT 3272, L.L.C.	DBA: CVS/PHARMACY # 03272	2371 E. GUADALUPE RD.	GILBERT	AZ	85234	04/01/2023
CHC28956-00	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	04/01/2023
CHC28956-03	GENOA HEALTHCARE LLC	460 NORTH MESA DR STE 201	SUITE 201P	MESA	AZ	85201	01/01/2022
CHC28956-03	GENOA HEALTHCARE LLC	1209 S 1ST AVE		PHOENIX	AZ	85003	01/01/2022
CHC28956-06	GENOA HEALTHCARE LLC	460 NORTH MESA DR STE 201	SUITE 201P	MESA	AZ	85201	01/01/2022	04/01/2024
CHC28956-01	GENOA HEALTHCARE LLC	1209 S 1ST AVE		PHOENIX	AZ	85003	01/01/2022
CHC28956-01	GENOA HEALTHCARE LLC	460 NORTH MESA DR STE 201	SUITE 201P	MESA	AZ	85201	01/01/2022
CHC28956-00	GENOA HEALTHCARE LLC	1209 S 1ST AVE		PHOENIX	AZ	85003	01/01/2022
CHC28956-04	GENOA HEALTHCARE LLC	460 NORTH MESA DR STE 201	SUITE 201P	MESA	AZ	85201	01/01/2022
CHC28956-04	GENOA HEALTHCARE LLC	3807 N 7TH ST STE P		PHOENIX	AZ	85014	01/01/2022
CHC28956-06	GENOA HEALTHCARE LLC	3807 N 7TH ST STE P		PHOENIX	AZ	85014	01/01/2022	04/01/2024
CHC28956-02	GENOA HEALTHCARE LLC	3807 N 7TH ST STE P		PHOENIX	AZ	85014	01/01/2022
CHC28956-05	GENOA HEALTHCARE LLC	3807 N 7TH ST STE P		PHOENIX	AZ	85014	01/01/2022
CHC28956-02	GENOA HEALTHCARE LLC	1209 S 1ST AVE		PHOENIX	AZ	85003	01/01/2022
CHC28956-05	GENOA HEALTHCARE LLC	1209 S 1ST AVE		PHOENIX	AZ	85003	01/01/2022
CHC28956-00	GENOA HEALTHCARE LLC	3807 N 7TH ST STE P		PHOENIX	AZ	85014	01/01/2022
CHC28956-04	GENOA HEALTHCARE LLC	1209 S 1ST AVE		PHOENIX	AZ	85003	01/01/2022
CHC28956-06	GENOA HEALTHCARE LLC	1209 S 1ST AVE		PHOENIX	AZ	85003	01/01/2022	04/01/2024
CHC28956-02	GENOA HEALTHCARE LLC	460 NORTH MESA DR STE 201	SUITE 201P	MESA	AZ	85201	01/01/2022
CHC28956-03	GENOA HEALTHCARE LLC	3807 N 7TH ST STE P		PHOENIX	AZ	85014	01/01/2022
CHC28956-00	GENOA HEALTHCARE LLC	460 NORTH MESA DR STE 201	SUITE 201P	MESA	AZ	85201	01/01/2022
CHC28956-01	GENOA HEALTHCARE LLC	3807 N 7TH ST STE P		PHOENIX	AZ	85014	01/01/2022
CHC28956-05	GENOA HEALTHCARE LLC	460 NORTH MESA DR STE 201	SUITE 201P	MESA	AZ	85201	01/01/2022
CHC28956-07	GENOA HEALTHCARE LLC	460 NORTH MESA DR STE 201	SUITE 201P	MESA	AZ	85201	01/01/2022
CHC28956-07	GENOA HEALTHCARE LLC	3807 N 7TH ST STE P		PHOENIX	AZ	85014	01/01/2022
CHC28956-07	GENOA HEALTHCARE LLC	1209 S 1ST AVE		PHOENIX	AZ	85003	01/01/2022
CHC28956-00	GENOA HEALTHCARE LLC	1101 NORTH CENTRAL AVE	STE 102	PHOENIX	AZ	85004	10/01/2022
CHC28956-00	GENOA HEALTHCARE LLC	334 WEST 10TH PLACE	SUITE 100, ROOM P	MESA	AZ	85201	04/01/2024
CHC28956-05	GENOA HEALTHCARE LLC	334 WEST 10TH PLACE	SUITE 100, ROOM P	MESA	AZ	85201	07/01/2024
CHC28956-03	GENOA HEALTHCARE, LLC	1705 W MAIN ST		MESA	AZ	85201-6920	01/01/2022	04/17/2023
CHC28956-06	GENOA HEALTHCARE, LLC	1705 W MAIN ST		MESA	AZ	85201-6920	01/01/2022	04/17/2023
CHC28956-01	GENOA HEALTHCARE, LLC	1705 W MAIN ST		MESA	AZ	85201-6920	01/01/2022	04/17/2023
CHC28956-04	GENOA HEALTHCARE, LLC	1705 W MAIN ST		MESA	AZ	85201-6920	01/01/2022	04/17/2023
CHC28956-05	GENOA HEALTHCARE, LLC	1705 W MAIN ST		MESA	AZ	85201-6920	01/01/2022	04/17/2023
CHC28956-00	GENOA HEALTHCARE, LLC	1705 W MAIN ST		MESA	AZ	85201-6920	01/01/2022	07/15/2022
CHC28956-02	GENOA HEALTHCARE, LLC	1705 W MAIN ST		MESA	AZ	85201-6920	01/01/2022	04/17/2023
CHC28956-07	GENOA HEALTHCARE, LLC	1705 W MAIN ST		MESA	AZ	85201-6920	01/01/2022	04/17/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 07078	3303 S. RURAL	TEMPE	AZ	85282	04/01/2023	07/20/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05038	2010 S. DOBSON RD.	CHANDLER	AZ	85286	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 04795	6015 E. BROWN ROAD	MESA	AZ	85205	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 07263	10707 W. CAMELBACK RD.	PHOENIX	AZ	85037	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 01720	21201 EAST OCOTILLO RD.,	QUEEN CREEK	AZ	85142	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 03436	2809 S. SOSSAMAN RD.	MESA	AZ	85212	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05026	1212 S. GREENFIELD RD.	MESA	AZ	85206	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 03143	990 E. WARNER RD.	CHANDLER	AZ	85225	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 09222	4275 W. THOMAS RD.	PHOENIX	AZ	85019	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	CVS/PHARMACY #10616	7547 E. SOUTHERN AVE.	MESA	AZ	85209	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05950	855 E. ELLIOT ROAD	TEMPE	AZ	85284	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 08365	2428 S VAL VISTA DR	GILBERT	AZ	85295	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05814	9950 E. GUADALUPE RD.	MESA	AZ	85212	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 00040	1424 W BASELINE RD	TEMPE	AZ	85283	04/01/2023	06/13/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 08366	1610 E CAMELBACK RD	PHOENIX	AZ	85016	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 07836	1151 E. MCKELLIPS RD.	MESA	AZ	85203	04/01/2023	04/11/2024
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 01744	6650 W. LOWER BUCKEYE RD.	PHOENIX	AZ	85043	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05892	5050 W. BASELINE RD.	LAVEEN	AZ	85339	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05812	5954 E. MCDOWELL RD.	MESA	AZ	85215	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05891	3170 S. HIGLEY RD.	GILBERT	AZ	85295	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 01719	7587 S. POWER RD.	QUEEN CREEK	AZ	85142	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 06718	5835 W. INDIAN SCHOOL RD.	PHOENIX	AZ	85031	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	CVS PHARMACY # 16564	1515 E WARNER RD	GILBERT	AZ	85296	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	CVS PHARMACY # 17075	5110 S POWER RD	MESA	AZ	85212	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA CVS/PHARMACY #10229	280 N. AVONDALE BLVD	AVONDALE	AZ	85323	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05029	9230 E. BROADWAY RD.	MESA	AZ	85208	04/01/2023
CHC28956-00	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 00033	1750 E BROADWAY RD	TEMPE	AZ	85282	10/01/2023
CHC28956-07	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 00033	1750 E BROADWAY RD	TEMPE	AZ	85282	07/01/2024
CHC28956-07	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05950	855 E. ELLIOT ROAD	TEMPE	AZ	85284	07/01/2024
CHC28956-00	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	07/01/2025
CHC28956-00	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	07/01/2025
CHC28956-00	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/01/2023
CHC28956-00	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	04/01/2023
CHC28956-00	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	04/01/2023
CHC28956-00	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	04/01/2023
CHC28956-00	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #3129	1002 EAST MCDOWELL ROAD	PHOENIX	AZ	85006	04/01/2025
CHC28956-00	THOMAS PHOENIX CVS, L.L.C.	DBA: CVS/PHARMACY # 03625	8245 W. THOMAS RD.	PHOENIX	AZ	85033	04/01/2023
CHC28956-00	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/01/2025
CHC28956-00	WAL-MART PHARMACY 10-2482	857 N DOBSON		MESA	AZ	85201	04/01/2025
CHC28956-00	WAL-MART PHARMACY 10-2768	1955 SO. STAPLEY DRIVE		MESA	AZ	85204	04/01/2025
CHC28956-00	WAL-MART PHARMACY 10-3799	240 WEST BASELINE ROAD		MESA	AZ	85210	04/01/2025
CHC28956-00	WAL-MART PHARMACY 10-5332	730 E MCKELLIPS RD		MESA (HORNE)	AZ	85203	04/01/2025
CHC28956-00	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/01/2025
CHC28956-00	WALGREEN ARIZONA DRUG CO	DBA: WALGREENS #10111	3434 W. SOUTHERN AVE	PHOENIX	AZ	85041	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA; WALGREENS #09460	40663 N. GANTZEL RD	SAN TAN VALLEY	AZ	85140-7008	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS #12334	1654 N PEBBLE CREEK PKWY	GOODYEAR	AZ	85395	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 09175	23477 W YUMA RD	BUCKEYE	AZ	85326	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05504	4249 W GLENDALE AVE	PHOENIX	AZ	85051	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	WALGREENS CENTRAL FILL #21372	120 N 83RD AVE STE 200	TOLLESON	AZ	85353	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03657	3361 NORTH LITCHFIELD RD	GOODYEAR	AZ	85395	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05775	8309 W GLENDALE AVE	GLENDALE	AZ	85305	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05668	8301 W CAMELBACK	PHOENIX	AZ	85037	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07387	10710 WEST MCDOWELL ROAD	AVONDALE	AZ	85392	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05222	9040 W. PEORIA AVE.	PEORIA	AZ	85345	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07026	12244 W CACTUS RD	EL MIRAGE	AZ	85335	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 04909	2921 N. 83RD AVE.	PHOENIX	AZ	85033	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05893	705 EAST MCDOWELL RD	PHOENIX	AZ	85006	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 01969	6006 N 67TH AVE	GLENDALE	AZ	85301	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03087	5625 E THOMAS RD	PHOENIX	AZ	85018	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 01272	5101 WEST INDIAN SCHOOL	PHOENIX	AZ	85031	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06872	2930 N 67TH AVE	PHOENIX	AZ	85033	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05776	1451 N DYSART ROAD	AVONDALE	AZ	85323	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06736	4410 W CACTUS ROAD	GLENDALE	AZ	85304-2332	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05937	4315 W MCDOWELL RD	PHOENIX	AZ	85035	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	WALGREENS SPECIALTY PHARMACY #16431	2302 N. CENTRAL AVE. SUITE 7	PHOENIX	AZ	85004	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03464	3402 N CENTRAL AVE	PHOENIX	AZ	85012	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07663	8280 W LOWER BUCKEYE ROAD	PHOENIX	AZ	85043	07/01/2023
CHC28956-00	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03387	10705 W INDIAN SCHOOL	AVONDALE	AZ	85392	07/01/2023
CHC28956-00	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/01/2025
CHC28956-00	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/01/2025
CHC28956-00	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	04/01/2025

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	2/9/2024 10:19:21 AM	2/17/2025 10:40:53 AM	2/17/2025 10:40 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/28/2024 12:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		598798	3/28/2024 12:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	3/28/2024 12:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/28/2024 12:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		801237	3/28/2024 12:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	3/28/2024 12:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/28/2024 12:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		871351	3/28/2024 12:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	3/28/2024 12:08 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1659927556	3/28/2024 12:08 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	3/28/2024 12:08 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1336480037	3/28/2024 12:08 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	3/28/2024 12:08 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1750712766	3/28/2024 12:08 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	3/28/2024 12:08 PM
Addresses	Main Address	Update	Recertification	8410 W Thomas Rd Ste 116 Phoenix, AZ 85037-3356	8410 W Thomas Rd Ste 116 Phoenix, AZ 85037-3356	2/9/2024 10:19 AM
Addresses	Billing Address	Update	Recertification	Valle del Sol 3877 North 7th Street Suite 400 Phoenix, AZ 85014	Valle del Sol, Inc. 3877 N 7th St Suite 400 Phoenix, AZ 85014	2/9/2024 10:19 AM
Details	Last Recertification Date	Update	Recertification	2/7/2023 5:21:00 PM	2/9/2024 10:19:21 AM	2/9/2024 10:19 AM
Contacts	Authorizing Official	Update	Change Request	Leon, Theresa Ms Valle del Sol 6023760507	Renaud, Mike President & Chief Executive Officer Valle Del Sol 6022586797-1320	11/21/2023 12:59 PM
Contacts	Primary Contact	Update	Profile Change Request	Zelaya, Rebecca Pharmacy Director Valle Del Sol 6022586797	Zelaya, Rebecca Pharmacy Director Valle Del Sol 6022586797-6213	3/20/2023 11:32 AM
Contacts	Primary Contact	Update	PC Change Request	Karuppana, Suganya Chief Medical Officer Valle del Sol, Inc. 6022586797-3810	Zelaya, Rebecca Pharmacy Director Valle Del Sol 6022586797	3/9/2023 3:40 PM
Details	Last Recertification Date	Update	Recertification	2/23/2022 5:36:27 PM	2/7/2023 5:21:00 PM	2/7/2023 5:21 PM
Contacts	Authorizing Official	Update	AO Change Request	Heredia, Carmen Chief Executive Officer Valle del Sol 6022586797-1320	Leon, Theresa Ms Valle del Sol 6023760507	2/7/2023 10:36 AM
Contacts	Primary Contact	Update	Profile Change Request	Karuppana, Suganya Chief Medical Officer/ Chief Medical Operations Officer Valle del Sol, Inc. 6022586797-3810	Karuppana, Suganya Chief Medical Officer Valle del Sol, Inc. 6022586797-3810	2/2/2023 6:19 PM
Addresses	Billing Address	Update	Recertification	Valle del Sol 3807 North 7th Street Phoenix, AZ 85014	Valle del Sol 3877 North 7th Street Suite 400 Phoenix, AZ 85014	2/23/2022 5:36 PM
Details	Last Recertification Date	Update	Recertification		2/23/2022 5:36:27 PM	2/23/2022 5:36 PM
Contacts	Primary Contact	Update	Profile Change Request	Karuppana, Suganya suganyak@valledelsol.com Chief Medical Officer Valle del Sol, Inc. 6022586797-3810	Karuppana, Suganya Chief Medical Officer/ Chief Medical Operations Officer Valle del Sol, Inc. 6022586797-3810	1/26/2022 12:26 PM
Contacts	Primary Contact	Update		Karuppana, Suganya Chief Medical Officer Valle del Sol, Inc. 6022586797-3810	Karuppana, Suganya suganyak@valledelsol.com Chief Medical Officer Valle del Sol, Inc. 6022586797-3810	1/25/2022 6:04 PM
Contacts	Primary Contact	Update	Group Change Request	Magallanez, Paul Chief of Business Development & Strategic Initiatives Valle del Sol Community Health 6232381506	Karuppana, Suganya Chief Medical Officer Valle del Sol, Inc. 6022586797-3810	1/6/2022 8:30 AM
Details	State	Update		Approved	Active	1/1/2022 12:01 AM
Contacts	Signed By	Insert	New Registration		Heredia, Carmen Chief Executive Officer Valle del Sol 6022586797-1320	11/1/2021 1:55 PM
Details	340B ID	Update	New Registration		CHC28956-04	11/1/2021 1:55 PM
Dates	Participating Approval Date	Update	New Registration		11/1/2021 1:55:24 PM	11/1/2021 1:55 PM
Details	State	Update	New Registration	Pending	Approved	11/1/2021 1:55 PM
Dates	Signed By Date	Update	New Registration		10/13/2021 12:22:09 PM	11/1/2021 1:55 PM
Dates	Start Date	Update	New Registration		1/1/2022 12:00:00 AM	11/1/2021 1:55 PM
Addresses	Main Address	Insert	New Registration		8410 W Thomas Rd Ste 116 Phoenix, AZ 85037-3356	10/13/2021 12:22 PM
Addresses	Billing Address	Insert	New Registration		Valle del Sol 3807 North 7th Street Phoenix, AZ 85014	10/13/2021 12:22 PM
Contacts	Primary Contact	Insert	New Registration		Magallanez, Paul Chief of Business Development & Strategic Initiatives Valle del Sol Community Health 6232381506	10/13/2021 12:22 PM
Contacts	Authorizing Official	Insert	New Registration		Heredia, Carmen Chief Executive Officer Valle del Sol 6022586797-1320	10/13/2021 12:22 PM
Details	Assistance Received From Date	Insert	New Registration			10/13/2021 12:22 PM
Details	Assistance Received To Date	Insert	New Registration			10/13/2021 12:22 PM
Details	Last Recertification Date	Insert	New Registration			10/13/2021 12:22 PM
Details	Grant Number	Insert	New Registration		H80CS28956	10/13/2021 12:22 PM
Details	340B ID	Insert	New Registration			10/13/2021 12:22 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/13/2021 12:22 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/13/2021 12:22 PM
Details	Medicare Provider Number	Insert	New Registration			10/13/2021 12:22 PM
Details	Entity Name	Insert	New Registration		Valle Del Sol, Inc.	10/13/2021 12:22 PM
Details	NOFO Number	Insert	New Registration			10/13/2021 12:22 PM
Details	Program Code	Insert	New Registration		CH	10/13/2021 12:22 PM
Details	Entity Subname	Insert	New Registration		Valle del Sol_ Maryvale_8410	10/13/2021 12:22 PM
Dates	Participating Approval Date	Insert	New Registration			10/13/2021 12:22 PM
Details	State	Insert	New Registration		Pending	10/13/2021 12:22 PM
Dates	Registration Date	Insert	New Registration		10/13/2021 12:22:06 PM	10/13/2021 12:22 PM
Dates	Signed By Date	Insert	New Registration			10/13/2021 12:22 PM
Dates	Start Date	Insert	New Registration			10/13/2021 12:22 PM
Terminations	Termination Comments	Insert	New Registration			10/13/2021 12:22 PM
Terminations	Termination Date	Insert	New Registration			10/13/2021 12:22 PM
Terminations	Termination Effective Date	Insert	New Registration			10/13/2021 12:22 PM
Terminations	Termination Reason	Insert	New Registration			10/13/2021 12:22 PM

340B Drug Pricing Program Database