Covered Entity Details

CH06757E Capitol City Family Health Center Inc (Active) - information as of 5/28/2025 5:20:16 PM

Main Details

Name

Capitol City Family Health Center Inc

Subdivision Name

CareSouth-Shreveport

Type

HRSA-Funded Health Center

Site ID

BPS-H80-033993

340B ID

CH06757E

Grant Number

H80CS00504

Additional Details

Current Program Status

Active

Registration Date

7/1/2022

Participating Start Date

10/1/2022

Participating Approval Date

7/6/2022

Last Recertification Date

2/11/2025

Contacts

Authorizing Official

Capitol City Family Health Center
Matthew Valliere, Chief Executive Officer
(225) 650-2026

Primary Contact

Capitol City Family Health Center
Maimouna Keita, Chief Financial Officer
(225) 650-2024

Addresses

Street Address

8730 Youree Dr Ste A-B
Shreveport, LA 71115-2500

Billing Address
Same as Street Address

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
LA		1750020053

Shipping Addresses

Shipping Address 1

Care South Pharmacy 3
8730 Youree Dr
Shreveport, LA 71115-2500

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH067570	Active	BPS-H80-000579	CAPITOL CITY FAMILY HEALTH CENTER INC dba CARESOUTH	CAPITOL CITY FAMILY HEALTH CENTER, INC dba CARESOUTH	3140 FLORIDA BLVD	BATON ROUGE	LA
CH06757B	Active	BPS-H80-011988	CAPITOL CITY FAMILY HEALTH CENTER INC dba CARESOUTH	Capitol City Family Health Center @ Donaldsonville	904 Catalpa Street	Donaldsonville	LA
CH06757C	Active	BPS-H80-013699	CAPITOL CITY FAMILY HEALTH CENTER INC dba CARESOUTH	Capitol City Family Health Center- Plaquemine (Iberville Parish)	59340 River West Drive	Plaquemine	LA
CH06757D	Active	BPS-H80-019658	Capitol City Family Health Center Inc	CARESOUTH BEHAVIORAL HEALTH AT ZACHARY, LA	4852 HWY 19, SUITE A	ZACHARY	LA
CH06757E	Active	BPS-H80-033993	Capitol City Family Health Center Inc	CareSouth-Shreveport	8730 Youree Dr Ste A-B	Shreveport	LA

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH067570	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	01/01/2022
CH067570	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	01/01/2022
CH067570	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	01/01/2022
CH067570	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	01/01/2022
CH067570	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	01/01/2022
CH067570	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	01/01/2022
CH067570	AHSSHC	EXPEDIEN RX PHARMACY	5050 WESLEY RD STE 120	APOPKA	FL	32712	07/01/2017
CH067570	AMAZON PHARMACY #001	4500 S PLEASANT VALLEY RD STE 201		AUSTIN	TX	78744-2911	04/01/2018
CH067570	AVITA PHARMACY 1037	AVITA DRUGS LLC-NOLA D/B/A AVITA PHARMAC	2519 CANAL ST	NEW ORLEANS	LA	70119	02/09/2012
CH06757B	AVITA PHARMACY 1037	AVITA DRUGS LLC-NOLA D/B/A AVITA PHARMAC	2519 CANAL ST	NEW ORLEANS	LA	70119	01/01/2013
CH067570	AVITA PHARMACY 1040	AVITA DRUGS, LLC D/B/A AVITA PHARMACY 10	6100 CORPORATE BLVD STE 250	BATON ROUGE	LA	70808	02/09/2012
CH067570	AZ PHARMACY, LLC	DBA AMAZON PHARMACY #002	3809 E WATKINS ST	PHOENIX	AZ	85034	07/01/2019
CH067570	BIOPLUS SPECIALTY PHARMACY LA, LLC	2731 MANHATTAN BLVD STE B17		HARVEY	LA	70058	04/01/2025
CH067570	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	07/01/2017
CH067570	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	10/01/2020
CH067570	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4740 VICTORY LN STE C	INDIANAPOLIS	IN	46203	10/01/2024
CH067570	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	145 S 79TH ST STE 70	CHANDLER	AZ	85226	10/01/2024
CH067570	BROWN'S PHARMACY LLC	1718 N FOSTER DR STE B		BATON ROUGE	LA	70806-1076	01/01/2015	12/01/2023
CH06757B	BROWN'S PHARMACY LLC	1718 N FOSTER DR STE B		BATON ROUGE	LA	70806-1076	01/01/2015
CH06757C	BROWN'S PHARMACY LLC	1718 N FOSTER DR STE B		BATON ROUGE	LA	70806-1076	01/01/2015
CH067570	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/01/2023
CH067570	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/01/2023
CH067570	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/01/2023
CH067570	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/01/2023
CH067570	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/01/2023
CH067570	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/01/2023
CH067570	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/01/2023
CH067570	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/01/2023
CH067570	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/01/2023
CH067570	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/01/2023
CH067570	CURANT HEALTH FLORIDA, LLC	11001 ROOSEVELT BLVD N STE 1400		ST PETERSBURG	FL	33716	04/01/2018
CH067570	CURANT HEALTH GEORGIA LLC	CURANT HEALTH	200 TECHNOLOGY CT SE BLDG 200 SUITE B	SMYRNA	GA	30082-5250	04/01/2018
CH067570	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/01/2023
CH067570	DELIVERCARERX PHARMACY LLC	DELIVERCARERX PHARMACY LLC	1471 E BUSINESS CENTER DR STE 200	MT PROSPECT	IL	60056	07/01/2017
CH067570	DOC-YOUR-DOSE PHARMACY		17275 HWY 77	GROSSE TETE	LA	70740	03/11/2010	12/01/2023
CH067570	DOGWOOD PHARMACY LLC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER RD STE K	GREENVILLE	SC	29607-6541	10/01/2020
CH067570	DOGWOOD PHARMACY, INC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER ROAD SUITE K	GREENVILLE	SC	29607-6540	10/01/2018
CH067570	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	01/01/2022
CH067570	EXACT CARE PHARMACY, LLC	8333 ROCKSIDE RD		CLEVELAND	OH	44125	10/01/2020	02/10/2023
CH067570	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	01/01/2022
CH067570	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	01/01/2022
CH067570	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	01/01/2022
CH067570	INVERNESS APOTHECARY TRINITY	24333 GORDON TERRY PARKWAY	SUITE B	TRINITY	AL	35673	07/01/2018
CH067570	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 01116	7777 BLUEBONNET BLVD,, SUITE 100	BATON ROUGE	LA	70810	07/01/2019
CH067570	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 01661	17122 AIRLINE HWY.	PRAIRIEVILLE	LA	70769	07/01/2019
CH067570	LOUISIANA CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY #1924	20501 OLD SCENIC HWY	ZACHARY	LA	70791-7365	07/01/2019
CH067570	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04761	3200 HIGLAND ROAD	BATON ROUGE	LA	70802	07/01/2019
CH067570	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05317	11430 FLORIDA BLVD	BATON ROUGE	LA	70815	07/01/2019
CH067570	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05319	5889 AIRLINE HWY	BATON ROUGE	LA	70805	07/01/2019
CH067570	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05322	9608 JEFFERSON HWY	BATON ROUGE	LA	70809	07/01/2019
CH067570	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05324	3384 GOVERNMENT ST	BATON ROUGE	LA	70806	07/01/2019
CH067570	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05343	15255 GEORGE ONEAL RD SUITE A	BATON ROUGE	LA	70817	07/01/2019
CH067570	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05354	1624 N. BURNSIDE	GONZALES	LA	70737	07/01/2019
CH067570	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05374	14360 WAX ROAD	BATON ROUGE	LA	70818	07/01/2019
CH067570	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05510	11705 COURSEY BLVD.	BATON ROUGE	LA	70816	07/01/2019	01/11/2023
CH067570	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05615	2520 PLANK RD	BATON ROUGE	LA	70805	07/01/2019
CH067570	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY #06124	7411 FLORIDA BLVD.	BATON ROUGE	LA	70806	07/01/2019
CH067570	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08309	5360 HIGHLAND RD.,	BATON ROUGE	LA	70808	07/01/2019
CH067570	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05321	1214 MAIN ST	BAKER	LA	70714	10/01/2019
CH067570	M.N. PHARMACY LLC	DBA AMAZON PHARMACY #003	6701 NW 7TH ST., STE. #199	MIAMI	FL	33126	04/01/2018
CH067570	NOAH'S PHARMACY	400 W ST FRANCIS ST		BRUSLY	LA	70719	07/01/2016	02/05/2024
CH067570	OPTUM PHARMACY 700, LLC	5700 DOT COM CT, STE 1000		OVIEDO	FL	32765	07/01/2024
CH067570	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	01/01/2025
CH067570	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	07/01/2023
CH067570	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	10/01/2024
CH067570	OPTUM PHARMACY 705, LLC	1893 GENERAL GEORGE PATTON DR	STE 106	FRANKLIN	TN	37067-2655	07/01/2023
CH067570	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	01/01/2025
CH067570	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	10/01/2024
CH067570	PILLPACK LLC	DBA PILLPACK BY AMAZON PHARMACY	250 COMMERCIAL ST STE 2012	MANCHESTER	NH	03101	04/01/2018
CH067570	PRAXIS SPECIALTY PHARMACY LLC	PRAXIS RX PHARMACY	5455 W WATERS AVE STE 214	TAMPA	FL	33634	07/01/2019
CH067570	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/01/2023
CH067570	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/01/2023
CH067570	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	07/01/2023
CH067570	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/01/2023
CH067570	PROPRIUM SOLUTIONS L.L.C	3710 YOUREE DR		SHREVEPORT	LA	71105	04/01/2024
CH067570	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	10/01/2018
CH067570	RELIANT MEDICAL LLC DBA RELIANT HEALTHCA	1004 N 19TH ST		MONROE	LA	71201-5734	07/01/2016
CH06757B	RELIANT MEDICAL LLC DBA RELIANT HEALTHCA	1004 N 19TH ST		MONROE	LA	71201-5734	07/01/2016
CH06757C	RELIANT MEDICAL LLC DBA RELIANT HEALTHCA	1004 N 19TH ST		MONROE	LA	71201-5734	07/01/2016
CH067570	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	10/01/2018
CH067570	SENDERRA RX PHARMACY	SENDERRA RX PARTNERS, LLC	3712 E PLANO PKWY STE 200	PLANO	TX	75074	07/01/2021	02/28/2024
CH067570	SPECIALTY CARE RX, LLC	150 COLLINS ST		MEMPHIS	TN	38112	07/01/2018
CH067570	VITAL RX LLC	237 CAHABA VALLEY PARKWAY		PELHAM	AL	35124	07/01/2018	02/05/2024
CH067570	VITAL RX OF LOUISIANA	6200 LESLIE LN		LAKE CHARLES	LA	70615	07/01/2018	02/05/2024
CH067570	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/01/2021
CH067570	WAL-MART PHARMACY 10-0401	59690 BELLVIEW DR		PLAQUEMINE	LA	70764	04/01/2018
CH067570	WAL-MART PHARMACY 10-0839	9350 CORTANA PL		BATON ROUGE	LA	70815	04/01/2018
CH067570	WAL-MART PHARMACY 10-1102	14507 PLANK ROAD		BAKER	LA	70714	04/01/2018
CH067570	WAL-MART PHARMACY 10-1206	3132 COLLEGE DR.		BATON ROUGE	LA	70808	04/01/2018
CH067570	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/01/2021
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 02995	3550 GOVERNMENT ST	BATON ROUGE	LA	70806	10/01/2016
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 09860	5955 AIRLINE HWY	BATON ROUGE	LA	70805-3202	10/01/2016	04/02/2024
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 02982	5450 PLANK ROAD	BATON ROUGE	LA	70805	10/01/2016
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 09753	1125 MARCHAND DR	DONALDSONVILLE	LA	70346-8596	10/01/2016	02/21/2023
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 02996	11297 FLORIDA BLVD	BATON ROUGE	LA	70815	10/01/2016
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 07836	3671 JOOR ROAD	BATON ROUGE	LA	70814-3104	10/01/2016
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS #13925	5298 HIGHLAND RD.	BATON ROUGE	LA	70808-6530	10/01/2016
CH067570	WALGREEN LOUISIANA CO., INC.	DBA WALGREENS SPECIALTY PHARMACY #16478	5555 ESSEN LN STE C	BATON ROUGE	LA	70809	01/01/2019
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 11498	5061 MAIN STREET	ZACHARY	LA	70791	01/01/2019
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 02980	4747 S SHERWOOD FOREST	BATON ROUGE	LA	70816	07/01/2019
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 07440	2001 ONEAL LANE	BATON ROUGE	LA	70816-3204	01/01/2020
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 03085	14444 COURSEY BLVD.	BATON ROUGE	LA	70817	04/01/2020
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 06028	9820 OLD HAMMOND HWY	BATON ROUGE	LA	70816	04/01/2020
CH067570	WALGREEN LOUISIANA CO., INC.	WALGREENS #17423	2152 S SHERWOOD FOREST BLVD	BATON ROUGE	LA	70816-8327	04/01/2020	11/07/2022
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 03610	12881 PERKINS RD.	BATON ROUGE	LA	70810	01/01/2021
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS #13875	6485 GROOM RD	BAKER	LA	70714	01/01/2021
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 07083	9983 BLUEBONNET BLVD	BATON ROUGE	LA	70810	07/01/2021
CH067570	WALGREEN LOUISIANA CO., INC.	DBA:WALGREENS #15366	220 N ALEXANDER AVE	PORT ALLEN	LA	70767-2514	07/01/2021
CH067570	WALGREEN LOUISIANA CO., INC.	WALGREENS #21157	24555 HIGHWAY 1	PLAQUEMINE	LA	70764-4171	07/01/2021
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 03047	5112 ESSEN LANE	BATON ROUGE	LA	70809	04/01/2022
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 03180	101 FLORIDA AVE. SE	DENHAM SPRINGS	LA	70726	04/01/2022
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 03399	7620 JEFFERSON HIGHWAY	BATON ROUGE	LA	70809	04/01/2022
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 06448	4485 PERKINS ROAD	BATON ROUGE	LA	70808-3034	04/01/2022
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 07795	6515 SULLIVAN RD	GREENWELL SPRINGS	LA	70739-3110	04/01/2022
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS #09518	15929 AIRLINE HWY	BATON ROUGE	LA	70817	04/01/2022
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 10400	34865 LA HWY 16	DENHAM SPRINGS	LA	70706-0669	04/01/2022
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS #11196	12506 HIGHWAY 73	GEISMAR	LA	70734-3209	04/01/2022
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS #11281	1607 N. AIRLINE HWY.	GONZALES	LA	70737	04/01/2022
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS #11413	105 WEST HIGHWAY 30	GONZALES	LA	70737-4802	04/01/2022
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS #11762	10200 FLORIDA BLVD	WALKER	LA	70785	04/01/2022
CH067570	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS #13080	3081 S. RANGE AVE	DENHAM SPRINGS	LA	70726	04/01/2022
CH067570	WALGREEN LOUISIANA CO., INC.	DBA:WALGREENS #13779	39527 HWY 42	PRAIRIEVILLE	LA	70769	04/01/2022
CH067570	WALGREEN LOUISIANA CO., INC.	WALGREENS #17647	2159 STARING LN	BATON ROUGE	LA	70810-1038	04/01/2022	11/17/2022
CH067570	Walgreens #21373	Walgreens Central Fill #21373	4100 Dale Earnhardt Way STE 200	Northlake	TX	76262	07/01/2023
CH067570	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/01/2024
CH067570	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/01/2024
CH067570	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/01/2024
CH067570	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	07/01/2023
CH067570	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	04/01/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	2/7/2024 1:07:26 PM	2/11/2025 2:49:33 PM	2/11/2025 2:49 PM
Addresses	Shipping Address	Delete	Change Request	Capitol City Family Health Center Inc. (CareSouth-Shreveport) 8730 Youree Dr. Suite B Shreveport, LA 71115		4/11/2024 12:25 PM
Addresses	Shipping Address	Insert	Change Request		Care South Pharmacy 3 8730 Youree Dr Shreveport, LA 71115-2500	4/11/2024 12:25 PM
Addresses	Main Address	Update	Recertification	8730 Youree Dr Ste A-B Shreveport, LA 70791-2500	8730 Youree Dr Ste A-B Shreveport, LA 71115-2500	2/7/2024 1:07 PM
Details	Last Recertification Date	Update	Recertification	2/9/2023 12:42:26 PM	2/7/2024 1:07:26 PM	2/7/2024 1:07 PM
Addresses	Shipping Address	Insert	Change Request		Capitol City Family Health Center Inc. (CareSouth-Shreveport) 8730 Youree Dr. Suite B Shreveport, LA 71115	10/31/2023 1:26 PM
Addresses	Main Address	Update	Change Request	8730 Youree Dr Ste A-B Shreveport, LA 71115-2500	8730 Youree Dr Ste A-B Shreveport, LA 70791-2500	10/31/2023 12:59 PM
Details	Last Recertification Date	Update	Recertification		2/9/2023 12:42:26 PM	2/9/2023 12:42 PM
Details	State	Update		Approved	Active	10/1/2022 12:01 AM
Contacts	Signed By	Insert	New Registration		Valliere, Matthew Chief Executive Officer Capitol City Family Health Center 2256502026	7/6/2022 7:40 AM
Details	340B ID	Update	New Registration		CH06757E	7/6/2022 7:40 AM
Dates	Participating Approval Date	Update	New Registration		7/6/2022 7:40:51 AM	7/6/2022 7:40 AM
Details	State	Update	New Registration	Pending	Approved	7/6/2022 7:40 AM
Dates	Signed By Date	Update	New Registration		7/1/2022 2:40:14 PM	7/6/2022 7:40 AM
Dates	Start Date	Update	New Registration		10/1/2022 12:00:00 AM	7/6/2022 7:40 AM
Addresses	Main Address	Insert	New Registration		8730 Youree Dr Ste A-B Shreveport, LA 71115-2500	7/1/2022 2:40 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1750020053	7/1/2022 2:40 PM
Medicaid Billing	NPI: State	Insert	New Registration		LA	7/1/2022 2:40 PM
Contacts	Primary Contact	Insert	New Registration		Keita, Maimouna Chief Financial Officer Capitol City Family Health Center 2256502024	7/1/2022 2:40 PM
Contacts	Authorizing Official	Insert	New Registration		Valliere, Matthew Chief Executive Officer Capitol City Family Health Center 2256502026	7/1/2022 2:40 PM
Details	Assistance Received From Date	Insert	New Registration			7/1/2022 2:40 PM
Details	Assistance Received To Date	Insert	New Registration			7/1/2022 2:40 PM
Details	Last Recertification Date	Insert	New Registration			7/1/2022 2:40 PM
Details	Grant Number	Insert	New Registration		H80CS00504	7/1/2022 2:40 PM
Details	340B ID	Insert	New Registration			7/1/2022 2:40 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/1/2022 2:40 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/1/2022 2:40 PM
Details	Medicare Provider Number	Insert	New Registration			7/1/2022 2:40 PM
Details	Entity Name	Insert	New Registration		Capitol City Family Health Center Inc	7/1/2022 2:40 PM
Details	NOFO Number	Insert	New Registration			7/1/2022 2:40 PM
Details	Program Code	Insert	New Registration		CH	7/1/2022 2:40 PM
Details	Entity Subname	Insert	New Registration		CareSouth-Shreveport	7/1/2022 2:40 PM
Dates	Participating Approval Date	Insert	New Registration			7/1/2022 2:40 PM
Details	State	Insert	New Registration		Pending	7/1/2022 2:40 PM
Dates	Registration Date	Insert	New Registration		7/1/2022 2:40:11 PM	7/1/2022 2:40 PM
Dates	Signed By Date	Insert	New Registration			7/1/2022 2:40 PM
Dates	Start Date	Insert	New Registration			7/1/2022 2:40 PM
Terminations	Termination Comments	Insert	New Registration			7/1/2022 2:40 PM
Terminations	Termination Date	Insert	New Registration			7/1/2022 2:40 PM
Terminations	Termination Effective Date	Insert	New Registration			7/1/2022 2:40 PM
Terminations	Termination Reason	Insert	New Registration			7/1/2022 2:40 PM

340B Drug Pricing Program Database