Covered Entity Details

CH09489E Venice Family Clinic (Active) - information as of 6/22/2025 12:02:12 AM

Main Details

Name

Venice Family Clinic

Subdivision Name

Venice Family Clinic - Carole Keen Carson Wellness Center

Type

HRSA-Funded Health Center

Site ID

BPS-H80-033914

340B ID

CH09489E

Grant Number

H80CS04217

Additional Details

Current Program Status

Active

Registration Date

11/29/2021

Participating Start Date

12/3/2021

Participating Approval Date

11/30/2021

Last Recertification Date

2/14/2025

Contacts

Authorizing Official

Venice Family Clinic
Mitesh G Popat, CEO
(310) 664-7901

Primary Contact

Venice Family Clinic
Isabela Mihai, Chief Compliance Officer
(310) 593-9594

Addresses

Street Address

270 E 223rd St
Carson, CA 90745-3804

Billing Address

Venice Family Clinic
604 Rose Avenue
Venice, CA 90291

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		1457924953,1669418513,1184885972,1285895078

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	AVITA PHARMACY 1005	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	2114 ARTESIA BLVD RM 111	REDONDO BEACH	CA	90278-3014	11/30/2021	12/07/2021	03/31/2023	07/26/2024
Contract Detail	AVITA PHARMACY 1024	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	330 E LAMBERT RD STE 120	BREA	CA	92821-4100	11/30/2021	12/07/2021	03/31/2023	07/26/2024
Contract Detail	AVITA PHARMACY 1025	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	3020 SATURN ST STE 100	BREA	CA	92821	11/30/2021	12/07/2021	03/31/2023	07/26/2024
Contract Detail	KOVACS-FREY PHARMACY	KOVACS FREY PHARMACY	2860 ARTESIA BLVD	REDONDO BEACH	CA	90278-9027	11/30/2021	12/07/2021	08/01/2024	08/13/2024
Contract Detail	MCCARTHY PHARMACY INC	DBA FREEMAN MEDICAL PHARMACY	301 N PRAIRIE AVE STE 110	INGLEWOOD	CA	90301	11/30/2021	12/07/2021	08/01/2024	08/13/2024
Contract Detail	MEDICAL CENTER PHARMACY	501 E HARDY ST STE 130		INGLEWOOD	CA	90301-4055	11/30/2021	12/07/2021	08/01/2024	08/13/2024

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH094890	Active	BPS-H80-000901	VENICE FAMILY CLINIC	VENICE FAMILY CLINIC	604 Rose Ave	Venice	CA
CH09489A	Active	BPS-H80-008650	VENICE FAMILY CLINIC	Irma Colen Health Center	4700 Inglewood Blvd STE 102	Culver City	CA
CH09489B	Active	BPS-H80-011791	VENICE FAMILY CLINIC	OPCC Access Center	503 Olympic Blvd	Santa Monica	CA
CH09489C	Active	BPS-H80-011833	VENICE FAMILY CLINIC	Robert Levine Family Health Center	905 Venice Blvd	Venice	CA
CH09489D	Active	BPS-H80-014381	VENICE FAMILY CLINIC	Venice Family Clinic - Simms/Mann Health and Wellness Center	2509 Pico Blvd	Santa Monica	CA
CH09489E	Active	BPS-H80-033914	Venice Family Clinic	Venice Family Clinic - Carole Keen Carson Wellness Center	270 E 223rd St	Carson	CA
CH09489F	Active	BPS-H80-033910	Venice Family Clinic	Venice South Bay Redondo Beach	2114 Artesia Blvd	Redondo Beach	CA
CH09489G	Active	BPS-H80-033913	Venice Family Clinic	Venice Family Clinic - South Bay Family Health Care - Gardena	742 W Gardena Blvd	Gardena	CA
CH09489H	Active	BPS-H80-033911	Venice Family Clinic	Venice Family Clinic - South Bay Family Health Care - OB	323 N Prairie Ave Ste 210	Inglewood	CA
CH09489J	Active	BPS-H80-033912	Venice Family Clinic	Venice Family Clinic - Inglewood Health Center	1091 S La Brea Ave	Inglewood	CA
CH09489K	Active	BPS-H80-031923	Venice Family Clinic	Venice Family Clinic- Meyer Outreach Van	604 Rose Ave	Venice	CA
CH09489L	Active	BPS-H80-019189	Venice Family Clinic	Venice Family Clinic - Santa Monica High School	601 Pico Blvd	Santa Monica	CA
CH09489M	Active	BPS-H80-019187	Venice Family Clinic	Venice Family Clinic - Sandy Segal Youth Health Center	4401 Elenda St	Culver City	CA
CH09489N	Active	BPS-H80-019190	Venice Family Clinic	Venice Family Clinic - Bill's Clinic at Safe Place for Youth (SPY)	2469 Lincoln Blvd	Venice	CA
CH09489P	Terminated	BPS-H80-031922	Venice Family Clinic	Venice Family Clinic – A Bridge Home Sunset	100 Sunset Ave	Venice	CA
CH09489Q	Active	BPS-H80-021925	Venice Family Clinic	Venice Family Clinic- Common Ground	622 Rose Ave	Venice	CA
CH09489R	Active	BPS-H80-015384	Venice Family Clinic	Venice Family Clinic - Lou Colen Children's Health and Wellness Center	4700 Inglewood Blvd Ste 101	Los Angeles	CA
CH09489S	Active	BPS-H80-037710	VENICE FAMILY CLINIC	Venice Family Clinic - allcove	514 N Prospect Ave, Ste 400	Redondo Beach	CA
CH09489T	Active	BPS-H80-037586	VENICE FAMILY CLINIC	Venice Family Clinic - Maxine Waters Health & Dignity Center	11802 York Ave	Hawthorne	CA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH094890	ACARIAHEALTH PHARMACY #13, INC	3302 GARFIELD AVE.		COMMERCE	CA	90040-3102	04/01/2017	12/31/2024
CH094890	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	01/01/2024	10/17/2024
CH094890	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	01/01/2024	10/17/2024
CH094890	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	01/01/2024	10/17/2024
CH094890	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	01/01/2024	10/17/2024
CH094890	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	01/01/2024	10/17/2024
CH094890	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	01/01/2024	10/17/2024
CH094890	AD-RX PHARMACY		6240 WILSHIRE BLVD.	LOS ANGELES	CA	90048	11/15/2012	01/31/2018
CH094890	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	07/01/2024
CH094890	AVITA PHARMACY 1005	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	2114 ARTESIA BLVD RM 111	REDONDO BEACH	CA	90278-3014	01/01/2022	03/31/2023
CH09489G	AVITA PHARMACY 1005	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	2114 ARTESIA BLVD RM 111	REDONDO BEACH	CA	90278-3014	12/07/2021	03/31/2023
CH09489E	AVITA PHARMACY 1005	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	2114 ARTESIA BLVD RM 111	REDONDO BEACH	CA	90278-3014	12/07/2021	03/31/2023
CH09489J	AVITA PHARMACY 1005	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	2114 ARTESIA BLVD RM 111	REDONDO BEACH	CA	90278-3014	12/07/2021	03/31/2023
CH09489H	AVITA PHARMACY 1005	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	2114 ARTESIA BLVD RM 111	REDONDO BEACH	CA	90278-3014	12/07/2021	03/31/2023
CH09489F	AVITA PHARMACY 1005	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	2114 ARTESIA BLVD RM 111	REDONDO BEACH	CA	90278-3014	12/07/2021	03/31/2023
CH094890	AVITA PHARMACY 1024	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	330 E LAMBERT RD STE 120	BREA	CA	92821-4100	01/01/2022	03/31/2023
CH09489G	AVITA PHARMACY 1024	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	330 E LAMBERT RD STE 120	BREA	CA	92821-4100	12/07/2021	03/31/2023
CH09489E	AVITA PHARMACY 1024	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	330 E LAMBERT RD STE 120	BREA	CA	92821-4100	12/07/2021	03/31/2023
CH09489J	AVITA PHARMACY 1024	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	330 E LAMBERT RD STE 120	BREA	CA	92821-4100	12/07/2021	03/31/2023
CH09489H	AVITA PHARMACY 1024	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	330 E LAMBERT RD STE 120	BREA	CA	92821-4100	12/07/2021	03/31/2023
CH09489F	AVITA PHARMACY 1024	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	330 E LAMBERT RD STE 120	BREA	CA	92821-4100	12/07/2021	03/31/2023
CH094890	AVITA PHARMACY 1025	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	3020 SATURN ST STE 100	BREA	CA	92821	01/01/2022	03/31/2023
CH09489G	AVITA PHARMACY 1025	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	3020 SATURN ST STE 100	BREA	CA	92821	12/07/2021	03/31/2023
CH09489E	AVITA PHARMACY 1025	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	3020 SATURN ST STE 100	BREA	CA	92821	12/07/2021	03/31/2023
CH09489J	AVITA PHARMACY 1025	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	3020 SATURN ST STE 100	BREA	CA	92821	12/07/2021	03/31/2023
CH09489H	AVITA PHARMACY 1025	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	3020 SATURN ST STE 100	BREA	CA	92821	12/07/2021	03/31/2023
CH09489F	AVITA PHARMACY 1025	PHARMEDQUEST PHARMACY SERVICES DBA AVITA	3020 SATURN ST STE 100	BREA	CA	92821	12/07/2021	03/31/2023
CH094890	BIOPLUS SPECIALTY PHARMACY CA	7373 LINCOLN WAY		GARDEN GROVE	CA	92841	07/01/2019	01/19/2023
CH094890	BIOPLUS SPECIALTY PHARMACY, INC	3200 LAKE EMMA RD UNIT 1000		LAKE MARY	FL	32746	04/01/2024
CH094890	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	05/09/2023
CH094890	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	05/09/2023
CH094890	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	05/09/2023
CH094890	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	05/09/2023
CH094890	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	05/09/2023
CH094890	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	05/09/2023
CH094890	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	05/09/2023
CH094890	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	05/09/2023
CH094890	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	05/09/2023
CH094890	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	05/09/2023
CH094890	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	05/09/2023
CH094890	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	05/09/2023
CH094890	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	05/09/2023
CH094890	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	01/01/2024	10/17/2024
CH094890	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	01/01/2024	10/17/2024
CH094890	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	01/01/2024	10/17/2024
CH094890	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	01/01/2024	10/17/2024
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09564	15700 SOUTH WESTERN AVENUE	GARDENA	CA	90247	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09477	5399 WEST CENTINELA AVENUE	LOS ANGELES	CA	90045	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10509	3627 EAST CESAR EAST CHAVEZ AVENUE	LOS ANGELES	CA	90063	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16747	2626 COLORADO BLVD	LOS ANGELES	CA	90041	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17595	6000 SEPULVEDA BLVD, SUITE 2250	CULVER CITY	CA	90230	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16964	2755 CANYON SPRINGS PKWY	RIVERSIDE	CA	92507	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09624	1747 NORTH CAHUENGA BOULEVARD	HOLLYWOOD	CA	90028	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #17780	420 BROADWAY	SANTA MONICA	CA	90401	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY 17804	8900 S. SEPULVEDA BLVD	LOS ANGELES	CA	90045	05/09/2023	01/29/2024
CH094890	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16649	3535 S LA CIENEGA BLVD	LOS ANGELES	CA	90016	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09608	2505 SANTA MONICA BOULEVARD	SANTA MONICA	CA	90404	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09686	4707 VENICE BLVD	LOS ANGELES	CA	90019	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09122	700 S. GAFFEY ST.	SAN PEDRO	CA	90731	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08831	3880 W. ROSECRANS AVE.	HAWTHORNE	CA	90250	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08847	3010 SOUTH SEPULVEDA BOULEVARD	LOS ANGELES	CA	90034	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08853	1645 EAST 103RD STREET	LOS ANGELES	CA	90002	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16670	3471 W CENTURY BLVD	INGLEWOOD	CA	90303	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09697	23841 MALIBU ROAD	MALIBU	CA	90265	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 05809	4775 W. ROSECRANS AVE.	HAWTHORNE	CA	90250	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16093	2169 W REDONDO BEACH BLVD	GARDENA	CA	90247	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09496	2900 N. SEPULVEDA BLVD.	MANHATTAN BEACH	CA	90266	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09707	14735 VENTURA BLVD.	SHERMAN OAKS	CA	91403	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09643	8425 LAUREL CANYON BLVD.	SUN VALLEY	CA	91352	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 07191	15718 HAWTHORNE BLVD (NEC)	LAWNDALE	CA	90260	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 04792	15232 SHERMAN WAY	VAN NUYS	CA	91405	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09584	4345 WEST CENTURY BOULEVARD	INGLEWOOD	CA	90304	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09568	4625 TORRANCE BOULEVARD	TORRANCE	CA	90503	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09647	2037 VERDUGO BLVD.	MONTROSE	CA	91020	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08837	222 N. MARKET ST.	INGLEWOOD	CA	90301	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10008	6265 EAST 2ND ST.	LONG BEACH	CA	90803	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10795	2115 ARTESIA BLVD, STE 100	REDONDO BEACH	CA	90278	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08860	11831 HAWTHORNE BOULEVARD	HAWTHORNE	CA	90250	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16048	10820 JEFFERSON BLVD	CULVER CITY	CA	90230	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09627	22050 VENTURA BLVD.	WOODLAND HILLS	CA	91364	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09580	5101 OBAMA BLVD	LOS ANGELES	CA	90016	05/09/2023	03/05/2025
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10146	12746 W. JEFFERSON BLVD., SUITE 3160	PLAYA VISTA	CA	90094	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08886	8601 SOUTH SEPULVEDA BOULEVARD	LOS ANGELES	CA	90045	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 06705	316 SOUTH PACIFIC COAST HWY.	REDONDO BEACH	CA	90277	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09661	6360 WEST THIRD STREET	LOS ANGELES	CA	90036	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09781	5985 WEST PICO BOULEVARD	LOS ANGELES	CA	90035	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09611	19424 SOLEDAD CANYON RD.	CANYON COUNTRY	CA	91351	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08892	5822 SOUTH VERMONT AVENUE	LOS ANGELES	CA	90044	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08839	150 WEST CARSON STREET	CARSON	CA	90745	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09507	650 EAST EL SEGUNDO BOULEVARD	LOS ANGELES	CA	90059	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09660	3751 WILSHIRE BOULEVARD	LOS ANGELES	CA	90010	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09726	1411 LINCOLN BOULEVARD	SANTA MONICA	CA	90401	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY # 1573	4744 LANKERSHIM BLVD.	NORTH HOLLYWOOD	CA	91602	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 05012	23806 MAIN STREET	CARSON	CA	90745	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08829	119 S. LINCOLN BLVD	VENICE	CA	90291	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09493	12315 VENICE BOULEVARD	MAR VISTA	CA	90066	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09626	1701 SOUTH WESTERN AVENUE	LOS ANGELES	CA	90006	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17096	1601 KINGSDALE AVE	REDONDO BEACH	CA	90278	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 17354	2700 W 120TH ST	HAWTHORNE	CA	90250	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY # 10022	1303 SEPULVEDA BLVD.	TORRANCE	CA	90501	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08868	5020 WEST 190TH STREET	TORRANCE	CA	90503	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08879	8985 VENICE BOULEVARD	LOS ANGELES	CA	90034	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08871	13171 MINDANAO WAY	MARINA DEL REY	CA	90292	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09576	10889 WELLWORTH AVENUE	LOS ANGELES	CA	90024	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 05022	7400 RESEDA BLVD.	RESEDA	CA	91335	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09578	3120 W. IMPERIAL HWY.	INGLEWOOD	CA	90303	05/09/2023
CH094890	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09582	3741 CRENSHAW BOULEVARD	LOS ANGELES	CA	90016	07/01/2025
CH094890	IPLAZA PHARMACY,INC.	PLAZA PHARMACY	3400 LOMITA BLVD STE 102	TORRANCE	CA	90505-4911	01/01/2024	09/16/2024
CH094890	KOVACS-FREY PHARMACY	KOVACS FREY PHARMACY	2860 ARTESIA BLVD	REDONDO BEACH	CA	90278-9027	01/01/2022	08/01/2024
CH09489G	KOVACS-FREY PHARMACY	KOVACS FREY PHARMACY	2860 ARTESIA BLVD	REDONDO BEACH	CA	90278-9027	12/07/2021	08/01/2024
CH09489E	KOVACS-FREY PHARMACY	KOVACS FREY PHARMACY	2860 ARTESIA BLVD	REDONDO BEACH	CA	90278-9027	12/07/2021	08/01/2024
CH09489J	KOVACS-FREY PHARMACY	KOVACS FREY PHARMACY	2860 ARTESIA BLVD	REDONDO BEACH	CA	90278-9027	12/07/2021	08/01/2024
CH09489H	KOVACS-FREY PHARMACY	KOVACS FREY PHARMACY	2860 ARTESIA BLVD	REDONDO BEACH	CA	90278-9027	12/07/2021	08/01/2024
CH09489F	KOVACS-FREY PHARMACY	KOVACS FREY PHARMACY	2860 ARTESIA BLVD	REDONDO BEACH	CA	90278-9027	12/07/2021	08/01/2024
CH094890	KROGER SPECIALTY PHARMACY CA 2	6240 WILSHIRE BLVD.		LOS ANGELES	CA	90048	04/01/2017	01/19/2023
CH094890	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA CVS/PHARMACY # 2289	19701 VANOWEN ST.	WINNETKA	CA	91306	05/09/2023
CH094890	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09146	575 S. CITRUS AVENUE	COVINA	CA	91723	05/09/2023
CH094890	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09325	11941 SAN VICENTE BLVD	LOS ANGELES	CA	90049	05/09/2023
CH094890	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 06582	255 MAIN STREET	VENICE	CA	90291	05/09/2023
CH094890	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09670	18441 VENTURA BLVD	TARZANA	CA	91356	05/09/2023
CH094890	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09212	1843 S LA CIENEGA BLVD	LOS ANGELES	CA	90035	05/09/2023
CH094890	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09503	8490 BEVERLY BLVD	LOS ANGELES	CA	90048	05/09/2023
CH094890	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 06976	4414 YORK BLVD	LOS ANGELES	CA	90041	05/09/2023
CH094890	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09563	3458 S SEPULVEDA BLVD	LOS ANGELES	CA	90034	05/09/2023
CH094890	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09985	8900 SEPULVEDA WESTWAY	LOS ANGELES	CA	90045	05/09/2023
CH094890	MCCARTHY PHARMACY INC	MCCARTHY DRUGS	12025 SAN VICENTE BLVD	LOS ANGELES	CA	90049	10/01/2016
CH094890	MCCARTHY PHARMACY INC	DBA FREEMAN MEDICAL PHARMACY	301 N PRAIRIE AVE STE 110	INGLEWOOD	CA	90301	01/01/2022	08/01/2024
CH09489G	MCCARTHY PHARMACY INC	DBA FREEMAN MEDICAL PHARMACY	301 N PRAIRIE AVE STE 110	INGLEWOOD	CA	90301	12/07/2021	08/01/2024
CH09489E	MCCARTHY PHARMACY INC	DBA FREEMAN MEDICAL PHARMACY	301 N PRAIRIE AVE STE 110	INGLEWOOD	CA	90301	12/07/2021	08/01/2024
CH09489J	MCCARTHY PHARMACY INC	DBA FREEMAN MEDICAL PHARMACY	301 N PRAIRIE AVE STE 110	INGLEWOOD	CA	90301	12/07/2021	08/01/2024
CH09489H	MCCARTHY PHARMACY INC	DBA FREEMAN MEDICAL PHARMACY	301 N PRAIRIE AVE STE 110	INGLEWOOD	CA	90301	12/07/2021	08/01/2024
CH09489F	MCCARTHY PHARMACY INC	DBA FREEMAN MEDICAL PHARMACY	301 N PRAIRIE AVE STE 110	INGLEWOOD	CA	90301	12/07/2021	08/01/2024
CH094890	MEDICAL CENTER PHARMACY	501 E HARDY ST STE 130		INGLEWOOD	CA	90301-4055	01/01/2022	08/01/2024
CH09489G	MEDICAL CENTER PHARMACY	501 E HARDY ST STE 130		INGLEWOOD	CA	90301-4055	12/07/2021	08/01/2024
CH09489E	MEDICAL CENTER PHARMACY	501 E HARDY ST STE 130		INGLEWOOD	CA	90301-4055	12/07/2021	08/01/2024
CH09489J	MEDICAL CENTER PHARMACY	501 E HARDY ST STE 130		INGLEWOOD	CA	90301-4055	12/07/2021	08/01/2024
CH09489H	MEDICAL CENTER PHARMACY	501 E HARDY ST STE 130		INGLEWOOD	CA	90301-4055	12/07/2021	08/01/2024
CH09489F	MEDICAL CENTER PHARMACY	501 E HARDY ST STE 130		INGLEWOOD	CA	90301-4055	12/07/2021	08/01/2024
CH094890	NEVADA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00082	6432 LOSEE RD.	NORTH LAS VEGAS	NV	89086	05/09/2023
CH094890	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	01/01/2024	08/16/2024
CH094890	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	01/01/2024	08/16/2024
CH094890	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	01/01/2024	08/16/2024
CH094890	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	01/01/2024	08/16/2024
CH094890	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	01/01/2024	08/16/2024
CH094890	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	01/01/2024	08/16/2024
CH094890	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	01/01/2024	08/16/2024
CH094890	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	01/01/2024	08/16/2024
CH094890	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	05/09/2023
CH094890	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	05/09/2023
CH094890	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	05/09/2023
CH094890	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	05/09/2023
CH094890	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY	8607 SANTA MONICA BOULEVARD	WEST HOLLYWOOD	CA	90069	04/01/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5485	888 LINCOLN BOULEVARD	VENICE	CA	90291	05/09/2023	04/15/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5463	3802 CULVER CENTER STREET	CULVER CITY	CA	90232	05/09/2023	06/01/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5456	11321 NATIONAL BOULEVARD	LOS ANGELES	CA	90064	05/09/2023	06/01/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5457	4046 SOUTH CENTINELA AVENUE	LOS ANGELES	CA	90066	05/09/2023	10/25/2023
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5464	11096 JEFFERSON BOULEVARD	CULVER CITY	CA	90230	05/09/2023	06/01/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5471	1208 WEST REDONDO BEACH BLVD.	GARDENA	CA	90247	05/09/2023	04/29/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5490	2412 PICO BOULEVARD	SANTA MONICA	CA	90405	05/09/2023	06/01/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5486	11340 CRENSHAW BOULEVARD	INGLEWOOD	CA	90303	05/09/2023	08/23/2023
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5488	1331 WILSHIRE BOULEVARD	SANTA MONICA	CA	90403	05/09/2023	06/01/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5424	226 NORTH LARCHMONT BLVD.	LOS ANGELES	CA	90004	05/09/2023	06/01/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5425	334 SOUTH VERMONT AVENUE	LOS ANGELES	CA	90020	05/09/2023	04/18/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5452	7900 WEST SUNSET BOULEVARD	LOS ANGELES	CA	90046	05/09/2023	06/01/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5426	1815 SOUTH VERMONT AVENUE	LOS ANGELES	CA	90006	05/09/2023	06/01/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5479	4410 EAST SLAUSON AVENUE	MAYWOOD	CA	90270	05/09/2023	06/01/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5811	1425 SOUTH H STREET	BAKERSFIELD	CA	93304	05/09/2023	06/01/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5435	1637 NORTH VERMONT AVENUE	LOS ANGELES	CA	90027	05/09/2023	06/01/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5513	501 SOUTH GAFFEY STREET	SAN PEDRO	CA	90731	05/09/2023	06/01/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #6263	27716 WEST MCBEAN PARKWAY	VALENCIA	CA	91354	05/09/2023	08/22/2023
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5455	11750 WILMINGTON AVENUE	LOS ANGELES	CA	90059	05/09/2023	03/15/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5470	220 EAST GRAND AVENUE	EL SEGUNDO	CA	90245	05/09/2023	06/01/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5462	300 NORTH CANON DRIVE	BEVERLY HILLS	CA	90210	05/09/2023	06/01/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5482	1720 AVIATION BOULEVARD	REDONDO BEACH	CA	90278	05/09/2023	06/01/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5448	4044 EAGLE ROCK BOULEVARD	LOS ANGELES	CA	90065	05/09/2023	10/31/2023
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5451	3230 WEST SLAUSON AVENUE	LOS ANGELES	CA	90043	05/09/2023	01/18/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5766	18112 CULVER DRIVE (UNIVERSITY PARK)	IRVINE	CA	92612	05/09/2023	06/01/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5484	9715 OTIS STREET	SOUTH GATE	CA	90280	05/09/2023	04/08/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5510	5520 WOODRUFF AVENUE	LAKEWOOD	CA	90713	05/09/2023	02/05/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #6346	211 CHERRY AVENUE	LONG BEACH	CA	90802	05/09/2023	06/01/2024
CH094890	THRIFTY PAYLESS, INC.	RITE AID #5708	9940 SIERRA AVENUE	FONTANA	CA	92335	05/09/2023	02/08/2024
CH094890	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/01/2024	10/13/2024
CH094890	WAL-MART PHARMACY 10-5604	14441 INGLEWOOD AVE		HAWTHORNE	CA	90250	01/01/2024	10/13/2024
CH094890	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/01/2024	10/13/2024
CH094890	WALGREEN CO	DBA: WALGREENS #10069	11983 HAWTHORNE BLVD	HAWTHORNE	CA	90250	05/09/2023
CH094890	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16561	1001 W CARSON ST STE K	TORRANCE	CA	90502	05/09/2023
CH094890	WALGREEN CO.	DBA: WALGREENS # 05848	20505 SHERMAN WAY	CANOGA PARK	CA	91306-3427	05/09/2023
CH094890	WALGREEN CO.	DBA: WALGREENS # 07481	22930 S WESTERN AVE	TORRANCE	CA	90501	05/09/2023
CH094890	WALGREEN CO.	DBA: WALGREENS # 07482	1800 W SLAUSON	LOS ANGELES	CA	90047-1126	05/09/2023
CH094890	WALGREEN CO.	DBA: WALGREENS #12720	1911 LINCOLN BLVD	SANTA MONICA	CA	90405	05/09/2023
CH094890	WALGREEN CO.	DBA: WALGREENS # 06413	230 N LABREA AVE	INGLEWOOD	CA	90301	05/09/2023
CH094890	WALGREEN CO.	DBA: WALGREENS # 06680	9031 ROSECRANS AVE	BELLFLOWER	CA	90706-2046	05/09/2023
CH094890	WALGREEN CO.	DBA: WALGREENS # 06974	3331 WEST CENTURY BLVD	INGLEWOOD	CA	90303	05/09/2023
CH094890	WALGREEN CO.	DBA: WALGREENS # 07016	3724 CRENSHAW BLVD	LOS ANGELES	CA	90016	05/09/2023
CH094890	WALGREEN CO.	DBA: WALGREENS # 07244	3570 ATLANTIC AVE	LONG BEACH	CA	90807-4516	05/09/2023
CH094890	WALGREEN CO.	DBA: WALGREENS # 06516	5467 WILSHIRE BLVD	LOS ANGELES	CA	90036	05/09/2023
CH094890	WALGREEN CO.	DBA: WALGREENS # 07070	4009 LINCOLN BLVD	MARINA DEL REY	CA	90292-5613	05/09/2023
CH094890	WALGREEN CO.	DBA: WALGREENS # 07175	1344 W REDONDO BEACH BLVD	GARDENA	CA	90247-3356	05/09/2023
CH094890	WALGREEN CO.	DBA: WALGREENS # 05591	24930 WESTERN AVE	HARBOR CITY	CA	90710	05/09/2023
CH094890	WALGREEN CO.	DBA: WALGREENS # 07629	5005 BALL ROAD	CYPRESS	CA	90630	05/09/2023
CH094890	WALGREEN CO.	DBA: WALGREENS # 09137	14250 PRAIRIE AVE	HAWTHORNE	CA	90250-7908	05/09/2023
CH094890	WALGREEN CO.	DBA: WALGREENS # 05182	60 N HIGHLAND SPRINGS AVE	BANNING	CA	92220	01/01/2025
CH094890	WALGREEN CO.	DBA: WALGREENS #12460	617 W 7TH ST STE 100	LOS ANGELES	CA	90017	01/01/2025	03/27/2025
CH094890	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16368	3745 S LA BREA AVE STE C & D	LOS ANGELES	CA	90016	04/01/2025
CH094890	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/01/2025
CH094890	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/01/2025
CH094890	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	01/01/2024	10/13/2024
CH094890	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024	10/13/2024
CH094890	WARM SPRINGS ROAD CVS, L.L.C.	CVS PHARMACY # 17465	350 W LAKE MEAD PKWY	HENDERSON	NV	89015	05/09/2023

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Mihai, Isabela Chief Compliance Officer Venice Family Clinic 4158705955	Mihai, Isabela Chief Compliance Officer Venice Family Clinic 3105939594	5/14/2025 4:53 PM
Addresses	Billing Address	Insert	Recertification		Venice Family Clinic 604 Rose Avenue Venice, CA 90291	2/14/2025 1:52 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1669418513	2/14/2025 1:52 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	2/14/2025 1:52 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184885972	2/14/2025 1:52 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	2/14/2025 1:52 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1285895078	2/14/2025 1:52 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	2/14/2025 1:52 PM
Details	Last Recertification Date	Update	Recertification	2/7/2024 1:19:34 PM	2/14/2025 1:52:37 PM	2/14/2025 1:52 PM
Details	Entity Subname	Update	Recertification	Venice Family Clinic - South Bay Family Health Care - Carson	Venice Family Clinic - Carole Keen Carson Wellness Center	2/14/2025 1:52 PM
Contacts	Primary Contact	Update	Change Request	Goodman, Kourtney Alexandria Executive Assistant to the Chief Strategy and Administration Officer Venice Family Clinic 3106647722	Mihai, Isabela Chief Compliance Officer Venice Family Clinic 4158705955	1/23/2025 2:24 PM
Contacts	Primary Contact	Update	PC Change Request	Huguet, Carla Antonieta Executive Assistant, Operations Venice Family Clinic 3109611906	Goodman, Kourtney Alexandria Executive Assistant to the Chief Strategy and Administration Officer Venice Family Clinic 3106647722	7/25/2024 5:36 PM
Details	Last Recertification Date	Update	Recertification	1/30/2023 3:57:43 PM	2/7/2024 1:19:34 PM	2/7/2024 1:19 PM
Contacts	Primary Contact	Update	PC Change Request	Ng, Sharon Director of Pharmacy Venice Family Clinic 3106647735	Huguet, Carla Antonieta Executive Assistant, Operations Venice Family Clinic 3109611906	3/28/2023 7:39 AM
Details	Last Recertification Date	Update	Recertification	2/8/2022 2:42:06 PM	1/30/2023 3:57:43 PM	1/30/2023 3:57 PM
Contacts	Authorizing Official	Update	AO Change Request	FORER, ELIZABETH BENSON EXECUTIVE DIRECTOR Venice Family Clinic 3106647901	Popat, Mitesh G CEO Venice Family Clinic 3106647901	1/23/2023 1:34 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457924953	2/8/2022 2:42 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	2/8/2022 2:42 PM
Details	Last Recertification Date	Update	Recertification		2/8/2022 2:42:06 PM	2/8/2022 2:42 PM
Details	State	Update	OPA Edit	Approved	Active	12/4/2021 3:08 AM
Dates	Start Date	Update	OPA Edit	1/1/2022 12:00:00 AM	12/3/2021 12:00:00 AM	12/4/2021 3:08 AM
Contacts	Signed By	Insert	New Registration		FORER, ELIZABETH BENSON EXECUTIVE DIRECTOR Venice Family Clinic 3106647901	11/30/2021 10:15 AM
Details	340B ID	Update	New Registration		CH09489E	11/30/2021 10:15 AM
Dates	Participating Approval Date	Update	New Registration		11/30/2021 10:15:41 AM	11/30/2021 10:15 AM
Details	State	Update	New Registration	Pending	Approved	11/30/2021 10:15 AM
Dates	Signed By Date	Update	New Registration		11/29/2021 6:41:44 PM	11/30/2021 10:15 AM
Dates	Start Date	Update	New Registration		1/1/2022 12:00:00 AM	11/30/2021 10:15 AM
Addresses	Main Address	Insert	New Registration		270 E 223rd St Carson, CA 90745-3804	11/29/2021 5:13 PM
Contacts	Authorizing Official	Insert	New Registration		FORER, ELIZABETH BENSON EXECUTIVE DIRECTOR Venice Family Clinic 3106647901	11/29/2021 5:13 PM
Contacts	Primary Contact	Insert	New Registration		Ng, Sharon Director of Pharmacy Venice Family Clinic 3106647735	11/29/2021 5:13 PM
Details	Assistance Received From Date	Insert	New Registration			11/29/2021 5:13 PM
Details	Assistance Received To Date	Insert	New Registration			11/29/2021 5:13 PM
Details	Last Recertification Date	Insert	New Registration			11/29/2021 5:13 PM
Details	Grant Number	Insert	New Registration		H80CS04217	11/29/2021 5:13 PM
Details	340B ID	Insert	New Registration			11/29/2021 5:13 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			11/29/2021 5:13 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			11/29/2021 5:13 PM
Details	Medicare Provider Number	Insert	New Registration			11/29/2021 5:13 PM
Details	Entity Name	Insert	New Registration		Venice Family Clinic	11/29/2021 5:13 PM
Details	NOFO Number	Insert	New Registration			11/29/2021 5:13 PM
Details	Program Code	Insert	New Registration		CH	11/29/2021 5:13 PM
Details	Entity Subname	Insert	New Registration		Venice Family Clinic - South Bay Family Health Care - Carson	11/29/2021 5:13 PM
Dates	Participating Approval Date	Insert	New Registration			11/29/2021 5:13 PM
Details	State	Insert	New Registration		Pending	11/29/2021 5:13 PM
Dates	Registration Date	Insert	New Registration		11/29/2021 5:13:41 PM	11/29/2021 5:13 PM
Dates	Signed By Date	Insert	New Registration			11/29/2021 5:13 PM
Dates	Start Date	Insert	New Registration			11/29/2021 5:13 PM
Terminations	Termination Comments	Insert	New Registration			11/29/2021 5:13 PM
Terminations	Termination Date	Insert	New Registration			11/29/2021 5:13 PM
Terminations	Termination Effective Date	Insert	New Registration			11/29/2021 5:13 PM
Terminations	Termination Reason	Insert	New Registration			11/29/2021 5:13 PM

340B Drug Pricing Program Database