Covered Entity Details

CH10112AN Multnomah, County of (Active) - information as of 4/25/2025 9:21:26 PM

Main Details

Name

Multnomah, County of

Subdivision Name

Multnomah Mobile Clinic

Type

HRSA-Funded Health Center

Site ID

BPS-H80-036709

340B ID

CH10112AN

Grant Number

H80CS00149

Additional Details

Current Program Status

Active

Registration Date

10/3/2023

Participating Start Date

1/1/2024

Participating Approval Date

10/12/2023

Last Recertification Date

2/10/2025

Contacts

Authorizing Official

Multnomah County
Jenna Green, Community Health Center Interim Executive Director
(503) 988-6734

Primary Contact

Multnomah County
Astrid Hollensteiner, Pharmacy Program Analyst
(503) 988-8850

Addresses

Street Address

1620 SE 190th Ave
Portland, OR 97233-5910

Billing Address

Multnomah County Mobile Clinic
619 NW 6th Ave
5th Floor
Portland, OR 97209

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
OR	123653,123729,025192,136424,500624853,123620,022959	1528073327,1275548059,1306851191,1528073319,1255645271,1396087631,1164130050

Shipping Addresses

Shipping Address 1

ROCKWOOD HEALTH CLINIC PHARMACY
2020 SE 182nd Avenue
Basement
Portland, OR 97233-5692

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	Address Cont.	City	State
CH10112A	Active	BPS-H80-003176	MULTNOMAH COUNTY	NORTHEAST HEALTH CENTER	5329 NE Martin Luther King Jr. Blvd	2nd Floor	Portland	OR
CH10112AA	Terminated	BPS-H80-003925	COUNTY OF MULTNOMAH	GRANT HIGH SCHOOL-BASED HEALTH CENTER	2245 NE 36th Ave		Portland	OR
CH10112AB	Active	BPS-H80-001584	MULTNOMAH COUNTY	JEFFERSON HIGH SCHOOL STUDENT HEALTH CENTER	5210 N Kerby Ave		Portland	OR
CH10112AC	Active	BPS-H80-001444	MULTNOMAH COUNTY	PARKROSE HIGH SCHOOL STUDENT HEALTH CENTER	12003 NE Shaver St		Portland	OR
CH10112AD	Active	BPS-H80-034075	MULTNOMAH COUNTY	Leodis V. McDaniel High School STUDENT HEALTH CENTER	2735 NE 82nd Ave		PORTLAND	OR
CH10112AE	Active	BPS-H80-027444	MULTNOMAH COUNTY	HIV Health Services Center	619 NW 6th Ave.	3rd Floor	PORTLAND	OR
CH10112AF	Active	BPS-H80-011058	MULTNOMAH COUNTY	FRANKLIN HIGH SCHOOL STUDENT HEALTH CENTER	5405 SE Woodward St		Portland	OR
CH10112AG	Active	BPS-H80-040066	MULTNOMAH COUNTY	Fernhill Health Center	5530 NE 42nd Ave		Portland	OR
CH10112AH	Terminated	BPS-H80-004653	COUNTY OF MULTNOMAH	HARRISON PARK K-8 STUDENT HEALTH CENTER	2225 SE 87th Ave		Portland	OR
CH10112AJ	Active	BPS-H80-012440	MULTNOMAH COUNTY	Billi Odegaard Dental Clinic	33 NW Broadway STE 380		Portland	OR
CH10112AK	Active	BPS-H80-013900	MULTNOMAH COUNTY	CENTENNIAL HIGH SCHOOL STUDENT HEALTH CENTER	3505 SE 182nd Ave		Gresham	OR
CH10112AL	Active	BPS-H80-010293	MULTNOMAH COUNTY	DAVID DOUGLAS HIGH SCHOOL STUDENT HEALTH CENTER	1034 SE 130th Ave		Portland	OR
CH10112AM	Active	BPS-H80-032023	MULTNOMAH COUNTY	Reynolds High School Student Health Center	1698 SW Cherry Park Rd Rm 506		Troutdale	OR
CH10112AN	Active	BPS-H80-036709	Multnomah, County of	Multnomah Mobile Clinic	1620 SE 190th Ave		Portland	OR
CH10112B	Active	BPS-H80-001904	MULTNOMAH COUNTY	NORTH PORTLAND HEALTH CENTER	9000 N Lombard St		Portland	OR
CH10112E	Terminated	BPS-H80-002163	COUNTY OF MULTNOMAH	WESTSIDE HEALTH CENTER	426 SW STARK STREET FL 5		PORTLAND	OR
CH10112F	Active	BPS-H80-005616	MULTNOMAH COUNTY	SOUTHEAST HEALTH CENTER	3653 SE 34th Ave		Portland	OR
CH10112G	Active	BPS-H80-003103	MULTNOMAH COUNTY	EAST COUNTY HEALTH CENTER	600 NE 8th St	3rd Floor	Gresham	OR
CH10112L	Active	BPS-H80-001601	MULTNOMAH COUNTY	MID COUNTY HEALTH CENTER	12710 SE Division St		Portland	OR
CH10112T	Active	BPS-H80-010664	MULTNOMAH COUNTY	Rockwood Community Health Center	2020 SE 182nd Avenue		Portland	OR
CH10112V	Terminated	BPS-H80-000383	COUNTY OF MULTNOMAH	CESAR CHAVEZ MIDDLE SCHOOL STUDENT HEALTH CENTER	5103 N Willis Blvd		Portland	OR
CH10112W	Active	BPS-H80-001890	MULTNOMAH COUNTY	CLEVELAND HIGH SCHOOL STUDENT HEALTH CENTER	3400 SE 26th Ave		Portland	OR
CH10112X	Terminated	BPS-H80-004403	COUNTY OF MULTNOMAH	GEORGE MIDDLE SCHOOL STUDENT HEALTH CENTER	10000 N Burr Ave		Portland	OR
CH10112Y	Active	BPS-H80-000895	MULTNOMAH COUNTY	ROOSEVELT HIGH SCHOOL STUDENT HEALTH CENTER	6941 N Central St		Portland	OR
CH10112Z	Terminated	BPS-H80-001176	COUNTY OF MULTNOMAH	LANE MIDDLE SCHOOL STUDENT HEALTH CENTER	7200 SE 60th Ave		Portland	OR

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Carve-In Effective Date	Termination Date
CH10112F	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #11280	538 SW 4TH AVENUE	PORTLAND	OR	97204	07/01/2019		03/31/2021
CH10112AE	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2819	1309 NW 23RD AVE.	PORTLAND	OR	97210	07/01/2021		05/01/2023

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/10/2025 5:32 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		022959	2/10/2025 5:32 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	2/10/2025 5:32 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1164130050	2/10/2025 5:32 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	2/10/2025 5:32 PM
Details	Last Recertification Date	Update	Recertification	2/7/2024 1:31:42 PM	2/10/2025 1:03:45 PM	2/10/2025 1:03 PM
Contacts	Authorizing Official	Update	Group Change Request	Perry, Jeff Finance Officer Multnomah County 5036796544	Green, Jenna Community Health Center Interim Executive Director Multnomah County 5039886734	4/12/2024 2:54 PM
Details	Last Recertification Date	Update	Recertification		2/7/2024 1:31:42 PM	2/7/2024 1:31 PM
Details	State	Update		Approved	Active	1/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Perry, Jeff Finance Officer Multnomah County 5036796544	10/12/2023 1:16 PM
Details	340B ID	Update	New Registration		CH10112AN	10/12/2023 1:16 PM
Dates	Participating Approval Date	Update	New Registration		10/12/2023 1:16:37 PM	10/12/2023 1:16 PM
Details	State	Update	New Registration	Pending	Approved	10/12/2023 1:16 PM
Dates	Signed By Date	Update	New Registration		10/5/2023 6:35:37 PM	10/12/2023 1:16 PM
Dates	Start Date	Update	New Registration		1/1/2024 12:00:00 AM	10/12/2023 1:16 PM
Addresses	Main Address	Insert	New Registration		1620 SE 190th Ave Portland, OR 97233-5910	10/3/2023 12:11 PM
Addresses	Billing Address	Insert	New Registration		Multnomah County Mobile Clinic 619 NW 6th Ave 5th Floor Portland, OR 97209	10/3/2023 12:11 PM
Addresses	Shipping Address	Insert	New Registration		ROCKWOOD HEALTH CLINIC PHARMACY 2020 SE 182nd Avenue Basement Portland, OR 97233-5692	10/3/2023 12:11 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/3/2023 12:11 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		123653	10/3/2023 12:11 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	10/3/2023 12:11 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/3/2023 12:11 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		123729	10/3/2023 12:11 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	10/3/2023 12:11 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/3/2023 12:11 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		025192	10/3/2023 12:11 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	10/3/2023 12:11 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/3/2023 12:11 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		136424	10/3/2023 12:11 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	10/3/2023 12:11 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/3/2023 12:11 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		500624853	10/3/2023 12:11 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	10/3/2023 12:11 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/3/2023 12:11 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		123620	10/3/2023 12:11 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	10/3/2023 12:11 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1528073327	10/3/2023 12:11 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	10/3/2023 12:11 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1275548059	10/3/2023 12:11 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	10/3/2023 12:11 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1306851191	10/3/2023 12:11 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	10/3/2023 12:11 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1528073319	10/3/2023 12:11 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	10/3/2023 12:11 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1255645271	10/3/2023 12:11 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	10/3/2023 12:11 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1396087631	10/3/2023 12:11 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	10/3/2023 12:11 PM
Contacts	Authorizing Official	Insert	New Registration		Perry, Jeff Finance Officer Multnomah County 5036796544	10/3/2023 12:11 PM
Contacts	Primary Contact	Insert	New Registration		Hollensteiner, Astrid Pharmacy Program Analyst Multnomah County 5039888850	10/3/2023 12:11 PM
Details	Assistance Received From Date	Insert	New Registration			10/3/2023 12:11 PM
Details	Assistance Received To Date	Insert	New Registration			10/3/2023 12:11 PM
Details	Last Recertification Date	Insert	New Registration			10/3/2023 12:11 PM
Details	Grant Number	Insert	New Registration		H80CS00149	10/3/2023 12:11 PM
Details	340B ID	Insert	New Registration			10/3/2023 12:11 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/3/2023 12:11 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/3/2023 12:11 PM
Details	Medicare Provider Number	Insert	New Registration			10/3/2023 12:11 PM
Details	Entity Name	Insert	New Registration		Multnomah, County of	10/3/2023 12:11 PM
Details	NOFO Number	Insert	New Registration			10/3/2023 12:11 PM
Details	Program Code	Insert	New Registration		CH	10/3/2023 12:11 PM
Details	Entity Subname	Insert	New Registration		Multnomah Mobile Clinic	10/3/2023 12:11 PM
Dates	Participating Approval Date	Insert	New Registration			10/3/2023 12:11 PM
Details	State	Insert	New Registration		Pending	10/3/2023 12:11 PM
Dates	Registration Date	Insert	New Registration		10/3/2023 12:11:09 PM	10/3/2023 12:11 PM
Dates	Signed By Date	Insert	New Registration			10/3/2023 12:11 PM
Dates	Start Date	Insert	New Registration			10/3/2023 12:11 PM
Terminations	Termination Comments	Insert	New Registration			10/3/2023 12:11 PM
Terminations	Termination Date	Insert	New Registration			10/3/2023 12:11 PM
Terminations	Termination Effective Date	Insert	New Registration			10/3/2023 12:11 PM
Terminations	Termination Reason	Insert	New Registration			10/3/2023 12:11 PM

340B Drug Pricing Program Database