340B Drug Pricing Program Database


FQHCLA430A MENTAL HEALTH CARE, INC. (Active) - information as of 5/7/2025 10:45:44 PM

Main Details
MENTAL HEALTH CARE, INC.
Gracepoint Wellness Clinic- North Tampa
Health Center Program Look-Alike
BPS-LAL-033969
FQHCLA430A
LALCS40297


Additional Details
Active
2/23/2022
2/24/2022
2/24/2022
2/13/2025

Contacts

Gracepoint
Roaya Tyson, CEO
(813) 965-2630

Mental Health Care dba Gracepoint
Joe Lallanilla, Chief Operating Officer
(813) 317-4648

Addresses

13601 Bruce B Downs Blvd Ste 131
Tampa, FL 33613-4610

Same as Street Address


  • Comments
  • Medicaid Billing
  • Shipping Addresses
  • Contract Pharmacies
  • Grantee Sites
  • Grantee Sites Contract Pharmacies
  • History
Comments
CommentLast Updated On 
No records to display.
Medicaid Billing

Yes
StateMedicaid NumberNPI Number
FL110069703,1174850001922777218,1952026692
Shipping Addresses

Mental Health Care, Inc. dba Gracepoint
5707 North 22nd Street
Tampa, FL 33610
Contract Pharmacies
Contract DetailPharmacy NameAddressAddress Cont.CityStateZip CodeApproval DateBegin DateCarve-In Effective DateTermination DateLast Updated On
Contract DetailACCREDO HEALTH GROUP INC3000 ERICSSON DRIVE, SUITE 100
WARRENDALEPA15086-750207/15/202210/01/2022 05/31/202407/16/2024
Contract DetailACCREDO HEALTH GROUP INC2040 W RIO SALADO PKWY STE 101B
TEMPEAZ85281-201007/15/202210/01/2022 05/31/202407/16/2024
Contract DetailACCREDO HEALTH GROUP INC1620 CENTURY CENTER PKWY # 109
MEMPHISTN38134-884907/15/202210/01/2022 05/31/202407/16/2024
Contract DetailACCREDO HEALTH GROUP, INC.2 BOULDEN CIR STE 1
NEW CASTLEDE19720-349207/15/202210/01/2022 05/31/202407/16/2024
Contract DetailACCREDO HEALTH GROUP, INC.6272 LEE VISTA BLVD STE 100
ORLANDOFL3282207/15/202210/01/2022 05/31/202407/16/2024
Contract DetailACCREDO HEALTH GROUP, INC.2825 W PERIMETER RD STE 112
INDIANAPOLISIN4624107/15/202210/01/2022 05/31/202407/16/2024
Contract DetailADVANCED CARE SCRIPTS, INCCVS/SPECIALTY OR CARELONRX SPECIALTY PHA 6251 CHANCELLOR DRIVE
SUITE 101 		ORLANDOFL3280910/22/202401/01/2025  01/01/2025
Contract DetailCAREMARK FLORIDA SPECIALTY PHARMACY LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 7930 WOODLAND CENTER BLVD STE 500
TAMPAFL3361410/05/202201/01/2023  01/01/2023
Contract DetailCAREMARK ILLINOIS SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 800 BIERMANN CT STE B
MOUNT PROSPECTIL6005610/05/202201/01/2023  01/01/2023
Contract DetailCAREMARK KANSAS SPECIALTY PHARMACYCVS/SPECIALTY OR CARELONRX SPECIALTY PHA 11162 RENNER BLVD
LENEXAKS6621910/05/202201/01/2023  01/01/2023
Contract DetailCAREMARK MASSACHUSETTS SPECIALTY PHARMACDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 25 BIRCH STREET, BLDG B, SUITE 100
MILFORDMA0175710/05/202201/01/2023  01/01/2023
Contract DetailCAREMARK MICHIGAN SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1307 ALLEN DR STE H
TROYMI4808310/05/202201/01/2023  01/01/2023
Contract DetailCAREMARK NEW JERSEY SPECIALTY PHCY, LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 180 PASSAIC AVE UNIT B-5
FAIRFIELDNJ0700410/05/202201/01/2023  01/01/2023
Contract DetailCAREMARK NORTH CAROLINA SPECIALTY PHARMADBA CVS/SPECIALTY OR CARELONRX SPECIALTY 10700 WORLD TRADE BLVD STE 110
RALEIGHNC2761710/05/202201/01/2023  01/01/2023
Contract DetailCAREMARK TENNESSEE SPECIALTY PHARMACY, LDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 8370 WOLF LAKE DR
STE 107 		BARTLETTTN3813310/05/202201/01/2023  01/01/2023
Contract DetailCAREMARK, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1127 BRYN MAWR AVE
SUITE A 		REDLANDSCA9237410/05/202201/01/2023  01/01/2023
Contract DetailCAREMARK, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 7251 S. EASTERN AVE.
LAS VEGASNV8911910/05/202201/01/2023  01/01/2023
Contract DetailCVS CAREMARKDBA CVS/CAREMARK OR CF# 11506 1 GREAT VALLEY BOULEVARD
WILKES BARREPA1870610/05/202201/01/2023  01/01/2023
Contract DetailCVS CAREMARK ADVANCED TECHNOLOGY PHARMACDBA CVS/CAREMARK 48067 1780 WALL ST
MT PROSPECTIL6005610/05/202201/01/2023  01/01/2023
Contract DetailCVS/SPECIALTY OR CARELONRX SPECIALTY PHACAREMARK, LLC 1001 SPINKS ROAD, STE 280
FLOWER MOUNDTX7502810/05/202201/01/2023  01/01/2023
Contract DetailESI MAIL PHARMACY SERVICEDBA EXPRESS SCRIPTS 7909 S HARDY DR STE 106
TEMPEAZ85284-111207/15/202210/01/2022 05/31/202407/17/2024
Contract DetailEXPRESS SCRIPTSESI MAIL PHARMACY SERVICE INC 4600 N HANLEY RD
SAINT LOUISMO6313407/15/202210/01/2022 05/31/202407/17/2024
Contract DetailEXPRESS SCRIPTS PHARMACY, INC.DBA EXPRESS SCRIPTS 2040 ROUTE 130 NORTH
BURLINGTONNJ0801607/15/202210/01/2022 05/31/202407/17/2024
Contract DetailEXPRESS SCRIPTS PHARMACY, INC.DBA EXPRESS SCRIPTS 4750 E. 450 S.
WHITESTOWNIN4607507/15/202210/01/2022 05/31/202407/17/2024
Contract DetailGENOA HEALTHCARE LLC5707 N 22ND ST
TAMPAFL3361007/15/202210/01/2022 01/01/202401/12/2024
Contract DetailGENOA HEALTHCARE LLC12512 BRUCE B DOWNS BLVD STE A142
TAMPAFL3361201/12/202404/01/2024  04/01/2024
Contract DetailHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 02760 2911 E. FOWLER AVE.
TAMPAFL3361207/15/202210/01/2022  10/01/2022
Contract DetailHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 00579 110 BULLARD PKWY
TEMPLE TERRACEFL3361707/15/202210/01/2022  10/01/2022
Contract DetailHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 03257 704 W MARTIN LUTHER KING JR BLVD
SEFFNERFL3358407/15/202210/01/2022 10/09/202401/27/2025
Contract DetailHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 03650 625 W. DR. MARTIN LUTHER KING JR BLVD
TAMPAFL3360307/15/202210/01/2022  10/01/2022
Contract DetailHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 05110 105 S PEBBLE BEACH BLVD
SUN CITY CENTERFL3357307/15/202210/01/2022 10/09/202401/27/2025
Contract DetailHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 00613 9202 N FLORIDA AVE
TAMPAFL3361207/15/202210/01/2022 09/11/202301/27/2025
Contract DetailHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 03638 10623 GIBSONTON DR
RIVERVIEWFL3357807/15/202210/01/2022  10/01/2022
Contract DetailHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 03811 2502 W HILLSBOROUGH AVE
TAMPAFL3361410/05/202201/01/2023 07/16/202401/27/2025
Contract DetailHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 02825 715 W. BRANDON BLVD.
BRANDONFL3351110/22/202401/01/2025  01/01/2025
Contract DetailOPTUM PHARMACY 702, LLC1050 PATROL RD
JEFFERSONVILLEIN4713010/16/202301/01/2024  01/01/2024
Contract DetailOPTUM PHARMACY 706, INC.30-30 47TH AVENUE SUITE 410
LONG ISLAND CITYNY1110110/16/202301/01/2024  01/01/2024
Contract DetailPROCARE PHARMACY DIRECT, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 105 MALL BOULEVARD
MONROEVILLEPA1514610/05/202201/01/2023  01/01/2023
Contract DetailPROCARE PHARMACY, L.L.C.DBA: CVS/PHARMACY #2909 1521 4TH AVE., SOUTH
BIRMINGHAMAL3523310/05/202201/01/2023  01/01/2023
Contract DetailPROCARE PHARMACY, L.L.C.DBA CVS/PHARMACY OR CARELONRX SPECIALTY ONE WATERFRONT PLAZA
500 ALA MOANA BLVD., BLDG 1 		HONOLULUHI9681310/05/202201/01/2023  01/01/2023
Contract DetailPROCARE PHARMACY, L.L.C.DBA CVS/PHARMACY #2923 3250 HARDEN ST. EXT. SUITE #300
COLUMBIASC2920310/05/202201/01/2023  01/01/2023
Contract DetailWALGREEN CODBA: WALGREENS #10398 13911 NINE EAGLES DR
TAMPAFL3362604/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CODBA: WALGREENS #10484 5605 FISHHAWK CROSSING BLVD
LITHIAFL3354704/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 07105 11010 BLOOMINGDALE AVENUE
RIVERVIEWFL3357804/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS #15236 13130 N DALE MABRY HWY
TAMPAFL33618-240604/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 03744 4738 W. GANDY BLVD.
TAMPAFL3361104/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 02818 2199 W BUSCH BLVD
TAMPAFL3361204/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 04523 930 PROVIDENCE ROAD
BRANDONFL3351104/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 07010 2110 EAST STATE RD 60
VALRICOFL33594-370104/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA WALGREENS SPECIALTY PHARMACY #21226 1506 W KENNEDY BLVD STE A
TAMPAFL3360604/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 06494 22829 STATE ROAD 54
LAND O LAKESFL3463904/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 03145 1860 E. FOWLER AVE.
TAMPAFL3361204/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 03829 8398 SHELDON ROAD
TAMPAFL3361504/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 13031 3863 S DALE MABRY HWY
TAMPAFL3361104/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 07569 20741 BRUCE B DOWNS BLVD
TAMPAFL3364704/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 12318 2480 US HIGHWAY 19
HOLIDAYFL3469104/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS #12673 2916 E. FLETCHER AVE.
TAMPAFL3361204/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 03128 5709 GUNN HIGHWAY
TAMPAFL3362504/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS #11790 36515 SR 54
ZEPHYRHILLSFL3354104/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 01925 13317 N BOULEVARD
TAMPAFL33612-331704/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 05437 17511 BRUCE B DOWNS BLVD.
TAMPAFL3364704/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 07815 3016 W GANDY BLVD
TAMPAFL3361104/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 06029 11115 E DR MLK JR BLVD
SEFFNERFL3358404/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 03793 4510 U.S. HIGHWAY 19
NEW PORT RICHEYFL3465204/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 03743 4651 W. KENNEDY BLVD.
TAMPAFL3360904/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 01934 1802 JAMES L REDMAN PKWY
PLANT CITYFL3356304/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 15518 703 COURT ST
CLEARWATERFL3375604/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 06751 514 E WINDHORST ROAD
BRANDONFL33510-253204/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 05576 7925 GUNN HIGHWAY
TAMPAFL3362604/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 04962 128 E. BRANDON BLVD.
BRANDONFL3351104/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS #12577 25201 WESLEY CHAPEL BOULEVARD
LUTZFL3355904/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 03555 1880 N BELCHER RD
CLEARWATERFL3376504/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 04034 1011 BLOOMINGDALE AVE.
VALRICOFL3359604/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.WALGREENS #16399 3100 E. FLETCHER AVE
SUITE A165 		TAMPAFL3361304/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 06192 6503 W WATERS AVE
TAMPAFL33634-220704/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 13824 18511 N. US HWY 41
LUTZFL3354904/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 05451 315 W. PLATT STREET
TAMPAFL3360604/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 15129 3518 HENDERSON BLVD
TAMPAFL3360904/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 07177 705 N PEBBLE BEACH BLVD
SUN CITY CENTERFL33573-535004/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS #09297 10427 BIG BEND RD
RIVERVIEWFL3357804/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 03459 2117 E HILLSBOROUGH AVE
TAMPAFL3361004/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 06860 3405 LITHIA PINECREST ROAD
VALRICOFL3359604/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 03863 4141 W HILLSBOROUGH AVE
TAMPAFL3361404/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 03351 6818 N. ARMENIA AVE.
TAMPAFL3360404/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 06611 1704 W HILLSBOROUGH AVE
TAMPAFL3360304/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 06412 28115 WESLEY CHAPEL BLVD
WESLEY CHAPELFL3354304/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 06674 8706 W HILLSBOROUGH AVE
TAMPAFL33615-370504/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 02887 1001 78TH ST SOUTH
TAMPAFL3361904/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 02975 15602 N. DALE MABRY
TAMPAFL3361804/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS #11246 7827 LAND O LAKES BLVD
LAND O LAKESFL3463804/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 06732 2102 W BAKER STREET
PLANT CITYFL33563-164304/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 09300 3890 VAN DYKE RD
LUTZFL3354804/15/202407/01/2024  07/01/2024
Contract DetailWALGREEN CO.DBA: WALGREENS # 04573 9202 N. 56TH STREET
TEMPLE TERRACEFL3361704/15/202407/01/2024  07/01/2024
Contract DetailWalgreens #21395Walgreens Central Fill #21395 5710 Young Pine Rd
OrlandoFL3282908/20/202410/01/2024 10/01/202408/21/2024
Grantee Sites
340B ID 340B StatusSiteIdNameSub NameAddressAddress Cont.CityState
FQHCLA430ActiveBPS-LAL-032216MENTAL HEALTH CARE, INC.Gracepoint Wellness Clinic5707 N. 22nd Street TampaFL
FQHCLA430AActiveBPS-LAL-033969MENTAL HEALTH CARE, INC.Gracepoint Wellness Clinic- North Tampa13601 Bruce B Downs Blvd Ste 131 TampaFL
Grantee Sites Contract Pharmacies
340B IDPharmacy NameAddressAddress Cont.CityStateZip CodeBegin DateCarve-In Effective DateTermination Date
FQHCLA430ACCREDO HEALTH GROUP INC1620 CENTURY CENTER PKWY # 109
MEMPHISTN38134-884901/01/2022 05/31/2024
FQHCLA430ACCREDO HEALTH GROUP INC3000 ERICSSON DRIVE, SUITE 100
WARRENDALEPA15086-750201/01/2022 05/31/2024
FQHCLA430ACCREDO HEALTH GROUP INC2040 W RIO SALADO PKWY STE 101B
TEMPEAZ85281-201001/01/2022 05/31/2024
FQHCLA430AACCREDO HEALTH GROUP INC3000 ERICSSON DRIVE, SUITE 100
WARRENDALEPA15086-750210/01/2022 05/31/2024
FQHCLA430AACCREDO HEALTH GROUP INC2040 W RIO SALADO PKWY STE 101B
TEMPEAZ85281-201010/01/2022 05/31/2024
FQHCLA430AACCREDO HEALTH GROUP INC1620 CENTURY CENTER PKWY # 109
MEMPHISTN38134-884910/01/2022 05/31/2024
FQHCLA430ACCREDO HEALTH GROUP, INC.2825 W PERIMETER RD STE 112
INDIANAPOLISIN4624101/01/2022 05/31/2024
FQHCLA430ACCREDO HEALTH GROUP, INC.6272 LEE VISTA BLVD STE 100
ORLANDOFL3282201/01/2022 05/31/2024
FQHCLA430ACCREDO HEALTH GROUP, INC.2 BOULDEN CIR STE 1
NEW CASTLEDE19720-349201/01/2022 05/31/2024
FQHCLA430AACCREDO HEALTH GROUP, INC.2 BOULDEN CIR STE 1
NEW CASTLEDE19720-349210/01/2022 05/31/2024
FQHCLA430AACCREDO HEALTH GROUP, INC.6272 LEE VISTA BLVD STE 100
ORLANDOFL3282210/01/2022 05/31/2024
FQHCLA430AACCREDO HEALTH GROUP, INC.2825 W PERIMETER RD STE 112
INDIANAPOLISIN4624110/01/2022 05/31/2024
FQHCLA430ADVANCED CARE SCRIPTS, INCCVS/SPECIALTY OR CARELONRX SPECIALTY PHA 6251 CHANCELLOR DRIVE
SUITE 101 		ORLANDOFL3280901/01/2025  
FQHCLA430AADVANCED CARE SCRIPTS, INCCVS/SPECIALTY OR CARELONRX SPECIALTY PHA 6251 CHANCELLOR DRIVE
SUITE 101 		ORLANDOFL3280901/01/2025  
FQHCLA430CAREMARK FLORIDA SPECIALTY PHARMACY LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 7930 WOODLAND CENTER BLVD STE 500
TAMPAFL3361401/01/2023  
FQHCLA430ACAREMARK FLORIDA SPECIALTY PHARMACY LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 7930 WOODLAND CENTER BLVD STE 500
TAMPAFL3361401/01/2023  
FQHCLA430CAREMARK ILLINOIS SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 800 BIERMANN CT STE B
MOUNT PROSPECTIL6005601/01/2023  
FQHCLA430ACAREMARK ILLINOIS SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 800 BIERMANN CT STE B
MOUNT PROSPECTIL6005601/01/2023  
FQHCLA430CAREMARK KANSAS SPECIALTY PHARMACYCVS/SPECIALTY OR CARELONRX SPECIALTY PHA 11162 RENNER BLVD
LENEXAKS6621901/01/2023  
FQHCLA430ACAREMARK KANSAS SPECIALTY PHARMACYCVS/SPECIALTY OR CARELONRX SPECIALTY PHA 11162 RENNER BLVD
LENEXAKS6621901/01/2023  
FQHCLA430CAREMARK MASSACHUSETTS SPECIALTY PHARMACDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 25 BIRCH STREET, BLDG B, SUITE 100
MILFORDMA0175701/01/2023  
FQHCLA430ACAREMARK MASSACHUSETTS SPECIALTY PHARMACDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 25 BIRCH STREET, BLDG B, SUITE 100
MILFORDMA0175701/01/2023  
FQHCLA430CAREMARK MICHIGAN SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1307 ALLEN DR STE H
TROYMI4808301/01/2023  
FQHCLA430ACAREMARK MICHIGAN SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1307 ALLEN DR STE H
TROYMI4808301/01/2023  
FQHCLA430CAREMARK NEW JERSEY SPECIALTY PHCY, LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 180 PASSAIC AVE UNIT B-5
FAIRFIELDNJ0700401/01/2023  
FQHCLA430ACAREMARK NEW JERSEY SPECIALTY PHCY, LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 180 PASSAIC AVE UNIT B-5
FAIRFIELDNJ0700401/01/2023  
FQHCLA430CAREMARK NORTH CAROLINA SPECIALTY PHARMADBA CVS/SPECIALTY OR CARELONRX SPECIALTY 10700 WORLD TRADE BLVD STE 110
RALEIGHNC2761701/01/2023  
FQHCLA430ACAREMARK NORTH CAROLINA SPECIALTY PHARMADBA CVS/SPECIALTY OR CARELONRX SPECIALTY 10700 WORLD TRADE BLVD STE 110
RALEIGHNC2761701/01/2023  
FQHCLA430CAREMARK TENNESSEE SPECIALTY PHARMACY, LDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 8370 WOLF LAKE DR
STE 107 		BARTLETTTN3813301/01/2023  
FQHCLA430ACAREMARK TENNESSEE SPECIALTY PHARMACY, LDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 8370 WOLF LAKE DR
STE 107 		BARTLETTTN3813301/01/2023  
FQHCLA430CAREMARK, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1127 BRYN MAWR AVE
SUITE A 		REDLANDSCA9237401/01/2023  
FQHCLA430ACAREMARK, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1127 BRYN MAWR AVE
SUITE A 		REDLANDSCA9237401/01/2023  
FQHCLA430CAREMARK, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 7251 S. EASTERN AVE.
LAS VEGASNV8911901/01/2023  
FQHCLA430ACAREMARK, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 7251 S. EASTERN AVE.
LAS VEGASNV8911901/01/2023  
FQHCLA430CVS CAREMARKDBA CVS/CAREMARK OR CF# 11506 1 GREAT VALLEY BOULEVARD
WILKES BARREPA1870601/01/2023  
FQHCLA430ACVS CAREMARKDBA CVS/CAREMARK OR CF# 11506 1 GREAT VALLEY BOULEVARD
WILKES BARREPA1870601/01/2023  
FQHCLA430CVS CAREMARK ADVANCED TECHNOLOGY PHARMACDBA CVS/CAREMARK 48067 1780 WALL ST
MT PROSPECTIL6005601/01/2023  
FQHCLA430ACVS CAREMARK ADVANCED TECHNOLOGY PHARMACDBA CVS/CAREMARK 48067 1780 WALL ST
MT PROSPECTIL6005601/01/2023  
FQHCLA430CVS/SPECIALTY OR CARELONRX SPECIALTY PHACAREMARK, LLC 1001 SPINKS ROAD, STE 280
FLOWER MOUNDTX7502801/01/2023  
FQHCLA430ACVS/SPECIALTY OR CARELONRX SPECIALTY PHACAREMARK, LLC 1001 SPINKS ROAD, STE 280
FLOWER MOUNDTX7502801/01/2023  
FQHCLA430ESI MAIL PHARMACY SERVICEDBA EXPRESS SCRIPTS 7909 S HARDY DR STE 106
TEMPEAZ85284-111204/01/2022 05/31/2024
FQHCLA430AESI MAIL PHARMACY SERVICEDBA EXPRESS SCRIPTS 7909 S HARDY DR STE 106
TEMPEAZ85284-111210/01/2022 05/31/2024
FQHCLA430EXPRESS SCRIPTSESI MAIL PHARMACY SERVICE INC 4600 N HANLEY RD
SAINT LOUISMO6313404/01/2022 05/31/2024
FQHCLA430AEXPRESS SCRIPTSESI MAIL PHARMACY SERVICE INC 4600 N HANLEY RD
SAINT LOUISMO6313410/01/2022 05/31/2024
FQHCLA430EXPRESS SCRIPTS PHARMACY, INC.DBA EXPRESS SCRIPTS 2040 ROUTE 130 NORTH
BURLINGTONNJ0801604/01/2022 05/31/2024
FQHCLA430EXPRESS SCRIPTS PHARMACY, INC.DBA EXPRESS SCRIPTS 4750 E. 450 S.
WHITESTOWNIN4607504/01/2022 05/31/2024
FQHCLA430AEXPRESS SCRIPTS PHARMACY, INC.DBA EXPRESS SCRIPTS 2040 ROUTE 130 NORTH
BURLINGTONNJ0801610/01/2022 05/31/2024
FQHCLA430AEXPRESS SCRIPTS PHARMACY, INC.DBA EXPRESS SCRIPTS 4750 E. 450 S.
WHITESTOWNIN4607510/01/2022 05/31/2024
FQHCLA430GENOA HEALTHCARE LLC5707 N 22ND ST
TAMPAFL3361001/01/2022 01/01/2024
FQHCLA430AGENOA HEALTHCARE LLC5707 N 22ND ST
TAMPAFL3361010/01/2022 01/01/2024
FQHCLA430AGENOA HEALTHCARE LLC12512 BRUCE B DOWNS BLVD STE A142
TAMPAFL3361204/01/2024  
FQHCLA430GENOA HEALTHCARE LLC12512 BRUCE B DOWNS BLVD STE A142
TAMPAFL3361204/01/2024  
FQHCLA430AHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 02760 2911 E. FOWLER AVE.
TAMPAFL3361210/01/2022  
FQHCLA430AHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 00579 110 BULLARD PKWY
TEMPLE TERRACEFL3361710/01/2022  
FQHCLA430HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 02760 2911 E. FOWLER AVE.
TAMPAFL3361210/01/2022  
FQHCLA430AHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 03257 704 W MARTIN LUTHER KING JR BLVD
SEFFNERFL3358410/01/2022 10/09/2024
FQHCLA430AHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 03650 625 W. DR. MARTIN LUTHER KING JR BLVD
TAMPAFL3360310/01/2022  
FQHCLA430AHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 05110 105 S PEBBLE BEACH BLVD
SUN CITY CENTERFL3357310/01/2022 10/09/2024
FQHCLA430AHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 00613 9202 N FLORIDA AVE
TAMPAFL3361210/01/2022 09/11/2023
FQHCLA430HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 00579 110 BULLARD PKWY
TEMPLE TERRACEFL3361710/01/2022  
FQHCLA430HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 03650 625 W. DR. MARTIN LUTHER KING JR BLVD
TAMPAFL3360310/01/2022  
FQHCLA430HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 03257 704 W MARTIN LUTHER KING JR BLVD
SEFFNERFL3358410/01/2022 10/09/2024
FQHCLA430AHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 03638 10623 GIBSONTON DR
RIVERVIEWFL3357810/01/2022  
FQHCLA430HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 03638 10623 GIBSONTON DR
RIVERVIEWFL3357810/01/2022  
FQHCLA430HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 05110 105 S PEBBLE BEACH BLVD
SUN CITY CENTERFL3357310/01/2022 10/09/2024
FQHCLA430HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 00613 9202 N FLORIDA AVE
TAMPAFL3361210/01/2022 09/11/2023
FQHCLA430HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 03811 2502 W HILLSBOROUGH AVE
TAMPAFL3361401/01/2023 07/16/2024
FQHCLA430AHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 03811 2502 W HILLSBOROUGH AVE
TAMPAFL3361401/01/2023 07/16/2024
FQHCLA430HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 02825 715 W. BRANDON BLVD.
BRANDONFL3351101/01/2025  
FQHCLA430AHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 02825 715 W. BRANDON BLVD.
BRANDONFL3351101/01/2025  
FQHCLA430AOPTUM PHARMACY 702, LLC1050 PATROL RD
JEFFERSONVILLEIN4713001/01/2024  
FQHCLA430OPTUM PHARMACY 702, LLC1050 PATROL RD
JEFFERSONVILLEIN4713001/01/2024  
FQHCLA430OPTUM PHARMACY 706, INC.30-30 47TH AVENUE SUITE 410
LONG ISLAND CITYNY1110101/01/2024  
FQHCLA430AOPTUM PHARMACY 706, INC.30-30 47TH AVENUE SUITE 410
LONG ISLAND CITYNY1110101/01/2024  
FQHCLA430PROCARE PHARMACY DIRECT, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 105 MALL BOULEVARD
MONROEVILLEPA1514601/01/2023  
FQHCLA430APROCARE PHARMACY DIRECT, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 105 MALL BOULEVARD
MONROEVILLEPA1514601/01/2023  
FQHCLA430PROCARE PHARMACY, L.L.C.DBA CVS/PHARMACY OR CARELONRX SPECIALTY ONE WATERFRONT PLAZA
500 ALA MOANA BLVD., BLDG 1 		HONOLULUHI9681301/01/2023  
FQHCLA430PROCARE PHARMACY, L.L.C.DBA CVS/PHARMACY #2923 3250 HARDEN ST. EXT. SUITE #300
COLUMBIASC2920301/01/2023  
FQHCLA430APROCARE PHARMACY, L.L.C.DBA: CVS/PHARMACY #2909 1521 4TH AVE., SOUTH
BIRMINGHAMAL3523301/01/2023  
FQHCLA430APROCARE PHARMACY, L.L.C.DBA CVS/PHARMACY OR CARELONRX SPECIALTY ONE WATERFRONT PLAZA
500 ALA MOANA BLVD., BLDG 1 		HONOLULUHI9681301/01/2023  
FQHCLA430APROCARE PHARMACY, L.L.C.DBA CVS/PHARMACY #2923 3250 HARDEN ST. EXT. SUITE #300
COLUMBIASC2920301/01/2023  
FQHCLA430PROCARE PHARMACY, L.L.C.DBA: CVS/PHARMACY #2909 1521 4TH AVE., SOUTH
BIRMINGHAMAL3523301/01/2023  
FQHCLA430AWALGREEN CODBA: WALGREENS #10398 13911 NINE EAGLES DR
TAMPAFL3362607/01/2024  
FQHCLA430AWALGREEN CODBA: WALGREENS #10484 5605 FISHHAWK CROSSING BLVD
LITHIAFL3354707/01/2024  
FQHCLA430WALGREEN CODBA: WALGREENS #10398 13911 NINE EAGLES DR
TAMPAFL3362607/01/2024  
FQHCLA430WALGREEN CODBA: WALGREENS #10484 5605 FISHHAWK CROSSING BLVD
LITHIAFL3354707/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 07105 11010 BLOOMINGDALE AVENUE
RIVERVIEWFL3357807/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS #12673 2916 E. FLETCHER AVE.
TAMPAFL3361207/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 03128 5709 GUNN HIGHWAY
TAMPAFL3362507/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS #15236 13130 N DALE MABRY HWY
TAMPAFL33618-240607/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 03744 4738 W. GANDY BLVD.
TAMPAFL3361107/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 04962 128 E. BRANDON BLVD.
BRANDONFL3351107/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 02887 1001 78TH ST SOUTH
TAMPAFL3361907/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 06412 28115 WESLEY CHAPEL BLVD
WESLEY CHAPELFL3354307/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 02818 2199 W BUSCH BLVD
TAMPAFL3361207/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS #11790 36515 SR 54
ZEPHYRHILLSFL3354107/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 04523 930 PROVIDENCE ROAD
BRANDONFL3351107/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 07010 2110 EAST STATE RD 60
VALRICOFL33594-370107/01/2024  
FQHCLA430AWALGREEN CO.DBA WALGREENS SPECIALTY PHARMACY #21226 1506 W KENNEDY BLVD STE A
TAMPAFL3360607/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 06494 22829 STATE ROAD 54
LAND O LAKESFL3463907/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 03145 1860 E. FOWLER AVE.
TAMPAFL3361207/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 03829 8398 SHELDON ROAD
TAMPAFL3361507/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 07010 2110 EAST STATE RD 60
VALRICOFL33594-370107/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS #15236 13130 N DALE MABRY HWY
TAMPAFL33618-240607/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 06674 8706 W HILLSBOROUGH AVE
TAMPAFL33615-370507/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 13031 3863 S DALE MABRY HWY
TAMPAFL3361107/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 05437 17511 BRUCE B DOWNS BLVD.
TAMPAFL3364707/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 02818 2199 W BUSCH BLVD
TAMPAFL3361207/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 07569 20741 BRUCE B DOWNS BLVD
TAMPAFL3364707/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS #12577 25201 WESLEY CHAPEL BOULEVARD
LUTZFL3355907/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 05576 7925 GUNN HIGHWAY
TAMPAFL3362607/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 02975 15602 N. DALE MABRY
TAMPAFL3361807/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 12318 2480 US HIGHWAY 19
HOLIDAYFL3469107/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 03863 4141 W HILLSBOROUGH AVE
TAMPAFL3361407/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS #12673 2916 E. FLETCHER AVE.
TAMPAFL3361207/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 04573 9202 N. 56TH STREET
TEMPLE TERRACEFL3361707/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 03128 5709 GUNN HIGHWAY
TAMPAFL3362507/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 07105 11010 BLOOMINGDALE AVENUE
RIVERVIEWFL3357807/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 15129 3518 HENDERSON BLVD
TAMPAFL3360907/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS #11790 36515 SR 54
ZEPHYRHILLSFL3354107/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 01925 13317 N BOULEVARD
TAMPAFL33612-331707/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 05437 17511 BRUCE B DOWNS BLVD.
TAMPAFL3364707/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 07815 3016 W GANDY BLVD
TAMPAFL3361107/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 06611 1704 W HILLSBOROUGH AVE
TAMPAFL3360307/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 03459 2117 E HILLSBOROUGH AVE
TAMPAFL3361007/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 06029 11115 E DR MLK JR BLVD
SEFFNERFL3358407/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 06494 22829 STATE ROAD 54
LAND O LAKESFL3463907/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 03793 4510 U.S. HIGHWAY 19
NEW PORT RICHEYFL3465207/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 05451 315 W. PLATT STREET
TAMPAFL3360607/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 03555 1880 N BELCHER RD
CLEARWATERFL3376507/01/2024  
FQHCLA430WALGREEN CO.WALGREENS #16399 3100 E. FLETCHER AVE
SUITE A165 		TAMPAFL3361307/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 06860 3405 LITHIA PINECREST ROAD
VALRICOFL3359607/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 03743 4651 W. KENNEDY BLVD.
TAMPAFL3360907/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 01934 1802 JAMES L REDMAN PKWY
PLANT CITYFL3356307/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 06029 11115 E DR MLK JR BLVD
SEFFNERFL3358407/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 06192 6503 W WATERS AVE
TAMPAFL33634-220707/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 09300 3890 VAN DYKE RD
LUTZFL3354807/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 15518 703 COURT ST
CLEARWATERFL3375607/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 06751 514 E WINDHORST ROAD
BRANDONFL33510-253207/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 06751 514 E WINDHORST ROAD
BRANDONFL33510-253207/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 03793 4510 U.S. HIGHWAY 19
NEW PORT RICHEYFL3465207/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 05576 7925 GUNN HIGHWAY
TAMPAFL3362607/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 04962 128 E. BRANDON BLVD.
BRANDONFL3351107/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS #12577 25201 WESLEY CHAPEL BOULEVARD
LUTZFL3355907/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS #09297 10427 BIG BEND RD
RIVERVIEWFL3357807/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 03744 4738 W. GANDY BLVD.
TAMPAFL3361107/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 03555 1880 N BELCHER RD
CLEARWATERFL3376507/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 04034 1011 BLOOMINGDALE AVE.
VALRICOFL3359607/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 03743 4651 W. KENNEDY BLVD.
TAMPAFL3360907/01/2024  
FQHCLA430AWALGREEN CO.WALGREENS #16399 3100 E. FLETCHER AVE
SUITE A165 		TAMPAFL3361307/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 15518 703 COURT ST
CLEARWATERFL3375607/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 06192 6503 W WATERS AVE
TAMPAFL33634-220707/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 13824 18511 N. US HWY 41
LUTZFL3354907/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 05451 315 W. PLATT STREET
TAMPAFL3360607/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 15129 3518 HENDERSON BLVD
TAMPAFL3360907/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 07177 705 N PEBBLE BEACH BLVD
SUN CITY CENTERFL33573-535007/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS #09297 10427 BIG BEND RD
RIVERVIEWFL3357807/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 03459 2117 E HILLSBOROUGH AVE
TAMPAFL3361007/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 03351 6818 N. ARMENIA AVE.
TAMPAFL3360407/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 03829 8398 SHELDON ROAD
TAMPAFL3361507/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 06860 3405 LITHIA PINECREST ROAD
VALRICOFL3359607/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 13031 3863 S DALE MABRY HWY
TAMPAFL3361107/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 03863 4141 W HILLSBOROUGH AVE
TAMPAFL3361407/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 07177 705 N PEBBLE BEACH BLVD
SUN CITY CENTERFL33573-535007/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 03351 6818 N. ARMENIA AVE.
TAMPAFL3360407/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 04523 930 PROVIDENCE ROAD
BRANDONFL3351107/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 06611 1704 W HILLSBOROUGH AVE
TAMPAFL3360307/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 12318 2480 US HIGHWAY 19
HOLIDAYFL3469107/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 06412 28115 WESLEY CHAPEL BLVD
WESLEY CHAPELFL3354307/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS #11246 7827 LAND O LAKES BLVD
LAND O LAKESFL3463807/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 03145 1860 E. FOWLER AVE.
TAMPAFL3361207/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 06732 2102 W BAKER STREET
PLANT CITYFL33563-164307/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 06674 8706 W HILLSBOROUGH AVE
TAMPAFL33615-370507/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 13824 18511 N. US HWY 41
LUTZFL3354907/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 02887 1001 78TH ST SOUTH
TAMPAFL3361907/01/2024  
FQHCLA430WALGREEN CO.DBA WALGREENS SPECIALTY PHARMACY #21226 1506 W KENNEDY BLVD STE A
TAMPAFL3360607/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 02975 15602 N. DALE MABRY
TAMPAFL3361807/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS #11246 7827 LAND O LAKES BLVD
LAND O LAKESFL3463807/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 06732 2102 W BAKER STREET
PLANT CITYFL33563-164307/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 07815 3016 W GANDY BLVD
TAMPAFL3361107/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 01934 1802 JAMES L REDMAN PKWY
PLANT CITYFL3356307/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 04034 1011 BLOOMINGDALE AVE.
VALRICOFL3359607/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 01925 13317 N BOULEVARD
TAMPAFL33612-331707/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 09300 3890 VAN DYKE RD
LUTZFL3354807/01/2024  
FQHCLA430WALGREEN CO.DBA: WALGREENS # 07569 20741 BRUCE B DOWNS BLVD
TAMPAFL3364707/01/2024  
FQHCLA430AWALGREEN CO.DBA: WALGREENS # 04573 9202 N. 56TH STREET
TEMPLE TERRACEFL3361707/01/2024  
FQHCLA430Walgreens #21395Walgreens Central Fill #21395 5710 Young Pine Rd
OrlandoFL3282908/21/2024  
FQHCLA430AWalgreens #21395Walgreens Central Fill #21395 5710 Young Pine Rd
OrlandoFL3282910/01/2024 10/01/2024
History
SectionFieldActionActivityValue BeforeValue AfterTimestamp 
DetailsLast Recertification DateUpdateRecertification1/31/2024 9:45:42 AM2/13/2025 2:48:34 PM2/13/2025 2:48 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False1/30/2025 4:37 PM
Medicaid BillingMedicaid: NumberInsertChange Request 1174850001/30/2025 4:37 PM
Medicaid BillingMedicaid: StateInsertChange Request FL1/30/2025 4:37 PM
Medicaid BillingNPI: NumberInsertChange Request 19520266921/30/2025 4:37 PM
Medicaid BillingNPI: StateInsertChange Request FL1/30/2025 4:37 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False5/30/2024 12:27 PM
Medicaid BillingMedicaid: NumberInsertChange Request 1100697035/30/2024 12:27 PM
Medicaid BillingMedicaid: StateInsertChange Request FL5/30/2024 12:27 PM
Medicaid BillingNPI: NumberInsertChange Request 19227772185/30/2024 12:27 PM
Medicaid BillingNPI: StateInsertChange Request FL5/30/2024 12:27 PM
DetailsLast Recertification DateUpdateRecertification2/2/2023 12:00:40 PM1/31/2024 9:45:42 AM1/31/2024 9:45 AM
ContactsAuthorizing OfficialUpdateProfile Change RequestTyson, Roaya COO Gracepoint 8139652630Tyson, Roaya CEO Gracepoint 81396526301/29/2024 3:45 PM
ContactsSigned ByUpdateProfile Change RequestTyson, Roaya COO Gracepoint 8139652630Tyson, Roaya CEO Gracepoint 81396526301/29/2024 3:45 PM
AddressesShipping AddressInsertGroup Change Request Mental Health Care, Inc. dba Gracepoint 5707 North 22nd Street Tampa, FL 3361011/17/2023 7:15 AM
DetailsLast Recertification DateUpdateRecertification 2/2/2023 12:00:40 PM2/2/2023 12:00 PM
ContactsPrimary ContactUpdateProfile Change RequestLallanilla, Joe Director of Analytics and Quality Mental Health Care dba Gracepoint 8133174648Lallanilla, Joe Chief Operating Officer Mental Health Care dba Gracepoint 81331746481/19/2023 10:43 AM
DetailsStateUpdateOPA EditApprovedActive2/24/2022 9:44 AM
DatesStart DateUpdateOPA Edit4/1/2022 12:00:00 AM2/24/2022 12:00:00 AM2/24/2022 9:44 AM
ContactsSigned ByInsertNew Registration Tyson, Roaya COO Gracepoint 81396526302/24/2022 9:24 AM
Details340B IDUpdateNew Registration FQHCLA430A2/24/2022 9:24 AM
DatesParticipating Approval DateUpdateNew Registration 2/24/2022 9:24:58 AM2/24/2022 9:24 AM
DetailsStateUpdateNew RegistrationPendingApproved2/24/2022 9:24 AM
DatesSigned By DateUpdateNew Registration 2/23/2022 3:20:49 PM2/24/2022 9:24 AM
DatesStart DateUpdateNew Registration 4/1/2022 12:00:00 AM2/24/2022 9:24 AM
AddressesMain AddressInsertNew Registration  13601 Bruce B Downs Blvd Ste 131 Tampa, FL 33613-46102/23/2022 3:20 PM
ContactsAuthorizing OfficialInsertNew Registration Tyson, Roaya COO Gracepoint 81396526302/23/2022 3:20 PM
ContactsPrimary ContactInsertNew Registration Lallanilla, Joe Director of Analytics and Quality Mental Health Care dba Gracepoint 81331746482/23/2022 3:20 PM
DetailsAssistance Received From DateInsertNew Registration  2/23/2022 3:20 PM
DetailsAssistance Received To DateInsertNew Registration  2/23/2022 3:20 PM
DetailsLast Recertification DateInsertNew Registration  2/23/2022 3:20 PM
DetailsGrant NumberInsertNew Registration LALCS402972/23/2022 3:20 PM
Details340B IDInsertNew Registration  2/23/2022 3:20 PM
DetailsIs Authorizing Official EHB DataInsertNew Registration  2/23/2022 3:20 PM
DatesLast Date That 340B Drugs PurchasedInsertNew Registration  2/23/2022 3:20 PM
DetailsMedicare Provider NumberInsertNew Registration  2/23/2022 3:20 PM
DetailsEntity NameInsertNew Registration MENTAL HEALTH CARE, INC.2/23/2022 3:20 PM
DetailsNOFO NumberInsertNew Registration  2/23/2022 3:20 PM
DetailsProgram CodeInsertNew Registration FQHCLA2/23/2022 3:20 PM
DetailsEntity SubnameInsertNew Registration Gracepoint Wellness Clinic- North Tampa2/23/2022 3:20 PM
DatesParticipating Approval DateInsertNew Registration  2/23/2022 3:20 PM
DetailsStateInsertNew Registration Pending2/23/2022 3:20 PM
DatesRegistration DateInsertNew Registration 2/23/2022 3:20:46 PM2/23/2022 3:20 PM
DatesSigned By DateInsertNew Registration  2/23/2022 3:20 PM
DatesStart DateInsertNew Registration  2/23/2022 3:20 PM
TerminationsTermination CommentsInsertNew Registration  2/23/2022 3:20 PM
TerminationsTermination DateInsertNew Registration  2/23/2022 3:20 PM
TerminationsTermination Effective DateInsertNew Registration  2/23/2022 3:20 PM
TerminationsTermination ReasonInsertNew Registration  2/23/2022 3:20 PM