340B Drug Pricing Program Database


FQHCLA463A Mazzoni Center (Active) - information as of 6/9/2025 12:00:35 AM

Main Details
Mazzoni Center
Bainbridge
Health Center Program Look-Alike
BPS-LAL-037664
FQHCLA463A
LALCS52965


Additional Details
Active
1/5/2024
4/1/2024
3/11/2024
2/17/2025

Contacts

Mazzoni Center
Alecia Manley, Executive Operating Officer
(215) 563-0652

Mazzoni Center
Valerie Canavin, Compliance Director
(215) 563-0652

Addresses

1348 Bainbridge St
Philadelphia, PA 19147-1810

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

No
Shipping Addresses

Same as Street Address
Contract Pharmacies
Contract DetailPharmacy NameAddressAddress Cont.CityStateZip CodeApproval DateBegin DateCarve-In Effective DateTermination DateLast Updated On
Contract DetailADVANCED CARE SCRIPTS, INCCVS/SPECIALTY OR CARELONRX SPECIALTY PHA 6251 CHANCELLOR DRIVE
SUITE 101 		ORLANDOFL3280903/11/202404/01/2024  04/01/2024
Contract DetailCAREMARK FLORIDA SPECIALTY PHARMACY LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 7930 WOODLAND CENTER BLVD STE 500
TAMPAFL3361403/11/202404/01/2024  04/01/2024
Contract DetailCAREMARK ILLINOIS SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 800 BIERMANN CT STE B
MOUNT PROSPECTIL6005603/11/202404/01/2024  04/01/2024
Contract DetailCAREMARK KANSAS SPECIALTY PHARMACYCVS/SPECIALTY OR CARELONRX SPECIALTY PHA 11162 RENNER BLVD
LENEXAKS6621903/11/202404/01/2024  04/01/2024
Contract DetailCAREMARK MASSACHUSETTS SPECIALTY PHARMACDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 25 BIRCH STREET, BLDG B, SUITE 100
MILFORDMA0175703/11/202404/01/2024  04/01/2024
Contract DetailCAREMARK MICHIGAN SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1307 ALLEN DR STE H
TROYMI4808303/11/202404/01/2024  04/01/2024
Contract DetailCAREMARK NEW JERSEY SPECIALTY PHCY, LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 180 PASSAIC AVE UNIT B-5
FAIRFIELDNJ0700403/11/202404/01/2024  04/01/2024
Contract DetailCAREMARK NORTH CAROLINA SPECIALTY PHARMADBA CVS/SPECIALTY OR CARELONRX SPECIALTY 10700 WORLD TRADE BLVD STE 110
RALEIGHNC2761703/11/202404/01/2024  04/01/2024
Contract DetailCAREMARK TENNESSEE SPECIALTY PHARMACY, LDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 8370 WOLF LAKE DR
STE 107 		BARTLETTTN3813303/11/202404/01/2024  04/01/2024
Contract DetailCAREMARK, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1127 BRYN MAWR AVE
SUITE A 		REDLANDSCA9237403/11/202404/01/2024  04/01/2024
Contract DetailCAREMARK, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 7251 S. EASTERN AVE.
LAS VEGASNV8911903/11/202404/01/2024  04/01/2024
Contract DetailCOORDINATED CARE NETWORKCOORDINATED CARE NETWORK 300 PENN CENTER BLVD STE 405
PITTSBURGHPA15235-551101/13/202504/01/2025  04/01/2025
Contract DetailCOORDINATED CARE NETWORK PHARMACY249 S 13TH ST
PHILADELPHIAPA1910701/13/202504/01/2025  04/01/2025
Contract DetailCOORDINATED CARE NETWORK PHARMACY100 N CAMERON ST. STE 201
HARRISBURGPA1710101/13/202504/01/2025  04/01/2025
Contract DetailCVS CAREMARKDBA CVS/CAREMARK OR CF# 11506 1 GREAT VALLEY BOULEVARD
WILKES BARREPA1870610/09/202401/01/2025  01/01/2025
Contract DetailCVS CAREMARK ADVANCED TECHNOLOGY PHARMACDBA CVS/CAREMARK 48067 1780 WALL ST
MT PROSPECTIL6005610/09/202401/01/2025  01/01/2025
Contract DetailCVS/SPECIALTY OR CARELONRX SPECIALTY PHACAREMARK, LLC 1001 SPINKS ROAD, STE 280
FLOWER MOUNDTX7502803/11/202404/01/2024  04/01/2024
Contract DetailCYSTIC FIBROSIS SERVICES, LLCDBA WALGREENS SPECIALTY PHARMACY #16280 10530 JOHN W ELLIOTT DR STE 200
FRISCOTX7503303/11/202404/01/2024 05/24/202405/30/2024
Contract DetailDELAWARE CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 00088 1005 DELAWARE AVE.
WILMINGTONDE1980607/11/202410/01/2024  10/01/2024
Contract DetailNEW JERSEY CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 00809 6815 TILTON ROAD
EGG HARBOR TWPNJ0823407/11/202410/01/2024  10/01/2024
Contract DetailNEW JERSEY CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 06900 1320 PARKWAY AVE.
EWINGNJ0862807/11/202410/01/2024  10/01/2024
Contract DetailOPTUM FRONTIER THERAPIES II, LLC6425 SANTA MARGARITA ST UNIT 110
LAS VEGASNV89118-191304/15/202407/01/2024  07/01/2024
Contract DetailOPTUM PHARMACY 702, LLC1050 PATROL RD
JEFFERSONVILLEIN4713004/15/202407/01/2024  07/01/2024
Contract DetailOPTUM PHARMACY 706, INC.30-30 47TH AVENUE SUITE 410
LONG ISLAND CITYNY1110104/15/202407/01/2024  07/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 04007 3925 WALNUT ST.
PHILADELPHIAPA1910407/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA CVS/PHARMACY # 10090 2132 SOUTH STREET
PHILADELPHIAPA1914607/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 05867 401 SPRING GARDEN ST.
PHILADELPHIAPA1912307/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01913 1405 SOUTH 10TH STREET
PHILADELPHIAPA1914707/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01064 1826-30 CHESTNUT STREET
PHILADELPHIAPA1910307/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02866 1046 MARKET ST.
PHILADELPHIAPA1910707/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02408 802 N LANSDOWNE AVE
DREXEL HILLPA1902607/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02986 7065 LINCOLN DRIVE
PHILADELPHIAPA1911907/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 00771 6150 N 5TH STREET
PHILADELPHIAPA1912007/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02398 3300-10 SOUTH BROAD STREET
PHILADELPHIAPA1914507/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02255 2640 E. CUMBERLAND ST.
PHILADELPHIAPA1912507/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02783 518 PORT ROYAL AVENUE
PHILADELPHIAPA1912807/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.CVS/PHARMACY # 11136 314 SOUTH 5TH STREET
PHILADELPHIAPA1910607/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 00371 6501 HARBISON AVENUE
PHILADELPHIAPA1914907/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02222 7520 CITY LINE AVE.
PHILADELPHIAPA1915107/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02785 1306 MACDADE BLVD.
WOODLYNPA1909407/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02166 3780 MAIN STREET
PHILADELPHIAPA1912707/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01296 5001 TOWNSHIP LINE ROAD
DREXEL HILLPA1902607/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01545 1500 SPRUCE STREET
PHILADELPHIAPA1910207/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.CVS/PHARMACY #11219 1138 N. 2ND STREET
PHILADELPHIAPA1912307/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.CVS/PHARMACY #11371 1717 NORTH 12TH STREET, UNIT F
PHILADELPHIAPA1912207/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02077 1901 WEST OREGON AVENUE
PHILADELPHIAPA1914507/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02121 6601 NORTH BROAD STREET
PHILADELPHIAPA1912607/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02704 4849 MARKET ST.
PHILADELPHIAPA1913907/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01196 7700 GERMANTOWN AVENUE
PHILADELPHIAPA1911807/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.CVS PHARMACY # 16775 1 MIFFLIN ST
PHILADELPHIAPA1914807/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02120 6344 STENTON AVENUE
PHILADELPHIAPA1913807/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02159 2320-26 FAIRMOUNT AVENUE
PHILADELPHIAPA1913007/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.CVS/PHARMACY # 11177 490 NORTH BROAD ST, SUITE 100
PHILADELPHIAPA1913007/11/202410/01/2024 02/12/202502/12/2025
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02755 4314 LOCUST STREET
PHILADELPHIAPA1910407/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01193 835 OLD YORK ROAD
JENKINTOWNPA1904607/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.CVS PHARMACY # 17207 4000 MONUMENT RD
PHILADELPHIAPA1913107/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.CVS/PHARMACY # 11170 1201 WALNUT ST
PHILADELPHIAPA1910707/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 08984 6701 RIDGE AVE.
PHILADELPHIAPA1912807/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA CVS/PHARMACY #11356 3401 ARAMINGO AVENUE
PHILADELPHIAPA1913407/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 00450 3401 WALNUT ST.
PHILADELPHIAPA1910407/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA CVS/PHARMACY # 10526 259 MARKET ST
PHILADELPHIAPA1910607/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 05726 701 E. KING ST.
SHIPPENSBURGPA1725707/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 03142 119 E. BALTIMORE AVE.
LANSDOWNEPA1905007/11/202410/01/2024  10/01/2024
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.CVS/PHARMACY # 10459 1919 MARKET ST. SUITE 150
PHILADELPHIAPA1910301/08/202504/01/2025  04/01/2025
Contract DetailPENNSYLVANIA CVS PHARMACY, L.L.C.CVS PHARMACY # 17252 600 HATTON DR
GLEN MILLSPA1934201/08/202504/01/2025  04/01/2025
Contract DetailPROCARE PHARMACY DIRECT, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 105 MALL BOULEVARD
MONROEVILLEPA1514603/11/202404/01/2024  04/01/2024
Contract DetailPROCARE PHARMACY, L.L.C.DBA CVS/PHARMACY #2923 3250 HARDEN ST. EXT. SUITE #300
COLUMBIASC2920303/11/202404/01/2024  04/01/2024
Contract DetailPROCARE PHARMACY, L.L.C.DBA CVS/PHARMACY # 02553 1117 WALNUT ST.
PHILADELPHIAPA1910703/11/202404/01/2024  04/01/2024
Contract DetailPROCARE PHARMACY, L.L.C.DBA: CVS/PHARMACY #2909 1521 4TH AVE., SOUTH
BIRMINGHAMAL3523303/11/202404/01/2024  04/01/2024
Contract DetailWALGREEN EASTERN CO INCDBA: WALGREENS # 04115 4201 N BROAD ST
PHILADELPHIAPA1914003/11/202404/01/2024 01/30/202504/01/2025
Contract DetailWALGREEN EASTERN CO. INC.DBA:WALGREENS #15336 1 SOUTH BROAD STREET
PHILADELPHIAPA1910703/11/202404/01/2024 05/24/202405/30/2024
Contract DetailWALGREEN EASTERN CO., INC.DBA: WALGREENS # 04429 150 N MACDADE BLVD.
GLENOLDENPA1903603/11/202404/01/2024  04/01/2024
Contract DetailWALGREEN EASTERN CO., INC.DBA: WALGREENS # 05522 1607 BRIDGE ST
PHILADELPHIAPA1912403/11/202404/01/2024 05/24/202405/30/2024
Contract DetailWALGREEN EASTERN CO., INC.DBA WALGREENS SPECIALTY PHARMACY #15316 1227 LOCUST ST
PHILADELPHIAPA1910703/11/202404/01/2024  04/01/2024
Contract DetailWALGREEN EASTERN CO., INC.DBA: WALGREENS # 04926 7001 FRANKFORD AVE
PHILADELPHIAPA1913503/11/202404/01/2024  04/01/2024
Contract DetailWALGREEN EASTERN CO., INC.DBA: WALGREENS # 03791 2014-24 S BROAD ST
PHILADELPHIAPA1914503/11/202404/01/2024 11/12/202411/12/2024
Contract DetailWALGREEN EASTERN CO., INC.DBA: WALGREENS #11780 2655 SOUTH TENTH ST.
PHILADELPHIAPA1914803/11/202404/01/2024 05/24/202405/30/2024
Contract DetailWALGREEN EASTERN CO., INC.DBA: WALGREENS # 06367 1809 E ALLEGHENY AVE
PHILADELPHIAPA1913403/11/202404/01/2024 05/24/202405/30/2024
Contract DetailWALGREEN EASTERN CO., INC.DBA: WALGREENS # 07336 1617 JOHN F KENNEDY BLVD LBBY W8
PHILADELPHIAPA1910303/11/202404/01/2024  04/01/2024
Contract DetailWALGREEN EASTERN CO., INC.DBA: WALGREENS 1101 LOCUST ST.
PHILADELPHIAPA1910703/11/202404/01/2024 01/29/202504/01/2025
Contract DetailWALGREEN EASTERN CO., INC.DBA WALGREENS SPECIALTY PHARMACY #16519 1334 BAINBRIDGE ST
PHILADELPHIAPA1914703/11/202404/01/2024  04/01/2024
Contract DetailWALGREEN EASTERN CO., INC.DBA: WALGREENS # 07543 2310 W OREGON AVE
PHILADELPHIAPA19145-412203/11/202404/01/2024  04/01/2024
Contract DetailWALGREEN EASTERN CO., INC.DBA: WALGREENS 1800 SOUTH ST.
PHILADELPHIAPA1914603/11/202404/01/2024  04/01/2024
Contract DetailWALGREEN EASTERN CO., INC.DBA: WALGREENS 300 N. 63RD ST.
PHILADELPHIAPA1913903/11/202404/01/2024 03/21/202504/01/2025
Contract DetailWALGREEN EASTERN CO., INC.DBA: WALGREENS 8828 FRANKFORD AVE.
PHILADELPHIAPA1913603/11/202404/01/2024  04/01/2024
Contract DetailWALGREEN EASTERN CO., INC.DBA: WALGREENS # 07224 119 E DEKALB PIKE
KING OF PRUSSIAPA1940603/11/202404/01/2024  04/01/2024
Contract DetailWALGREENS SPECIALTY PHARMACY, LLCDBA WALGREENS SPECIALTY PHARMACY #16287 130 ENTERPRISE DR
PITTSBURGHPA1527503/11/202404/01/2024  04/01/2024
Contract DetailWALGREENS SPECIALTY PHARMACY, LLCDBA WALGREENS SPECIALTY PHARMACY #15438 41460 HAGGERTY CIR S
CANTONMI4818803/11/202404/01/2024 05/24/202405/30/2024
Contract DetailWALGREENS SPECIALTY PHARMACY, LLCDBA WALGREENS SPECIALTY PHARMACY #15443 10530 JOHN W ELLIOTT DR STE 100
FRISCOTX7503303/11/202404/01/2024 05/24/202405/30/2024
Grantee Sites
340B ID 340B StatusSiteIdNameSub NameAddressAddress Cont.CityState
FQHCLA463ActiveBPS-LAL-037665Mazzoni CenterWashington West1201 Locust St. PhiladelphiaPA
FQHCLA463AActiveBPS-LAL-037664Mazzoni CenterBainbridge1348 Bainbridge St PhiladelphiaPA
Grantee Sites Contract Pharmacies
340B IDPharmacy NameAddressAddress Cont.CityStateZip CodeBegin DateCarve-In Effective DateTermination Date
FQHCLA463AADVANCED CARE SCRIPTS, INCCVS/SPECIALTY OR CARELONRX SPECIALTY PHA 6251 CHANCELLOR DRIVE
SUITE 101 		ORLANDOFL3280904/01/2024  
FQHCLA463ADVANCED CARE SCRIPTS, INCCVS/SPECIALTY OR CARELONRX SPECIALTY PHA 6251 CHANCELLOR DRIVE
SUITE 101 		ORLANDOFL3280904/01/2024  
FQHCLA463ACAREMARK FLORIDA SPECIALTY PHARMACY LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 7930 WOODLAND CENTER BLVD STE 500
TAMPAFL3361404/01/2024  
FQHCLA463CAREMARK FLORIDA SPECIALTY PHARMACY LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 7930 WOODLAND CENTER BLVD STE 500
TAMPAFL3361404/01/2024  
FQHCLA463CAREMARK ILLINOIS SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 800 BIERMANN CT STE B
MOUNT PROSPECTIL6005604/01/2024  
FQHCLA463ACAREMARK ILLINOIS SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 800 BIERMANN CT STE B
MOUNT PROSPECTIL6005604/01/2024  
FQHCLA463CAREMARK KANSAS SPECIALTY PHARMACYCVS/SPECIALTY OR CARELONRX SPECIALTY PHA 11162 RENNER BLVD
LENEXAKS6621904/01/2024  
FQHCLA463ACAREMARK KANSAS SPECIALTY PHARMACYCVS/SPECIALTY OR CARELONRX SPECIALTY PHA 11162 RENNER BLVD
LENEXAKS6621904/01/2024  
FQHCLA463CAREMARK MASSACHUSETTS SPECIALTY PHARMACDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 25 BIRCH STREET, BLDG B, SUITE 100
MILFORDMA0175704/01/2024  
FQHCLA463ACAREMARK MASSACHUSETTS SPECIALTY PHARMACDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 25 BIRCH STREET, BLDG B, SUITE 100
MILFORDMA0175704/01/2024  
FQHCLA463ACAREMARK MICHIGAN SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1307 ALLEN DR STE H
TROYMI4808304/01/2024  
FQHCLA463CAREMARK MICHIGAN SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1307 ALLEN DR STE H
TROYMI4808304/01/2024  
FQHCLA463CAREMARK NEW JERSEY SPECIALTY PHCY, LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 180 PASSAIC AVE UNIT B-5
FAIRFIELDNJ0700404/01/2024  
FQHCLA463ACAREMARK NEW JERSEY SPECIALTY PHCY, LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 180 PASSAIC AVE UNIT B-5
FAIRFIELDNJ0700404/01/2024  
FQHCLA463CAREMARK NORTH CAROLINA SPECIALTY PHARMADBA CVS/SPECIALTY OR CARELONRX SPECIALTY 10700 WORLD TRADE BLVD STE 110
RALEIGHNC2761704/01/2024  
FQHCLA463ACAREMARK NORTH CAROLINA SPECIALTY PHARMADBA CVS/SPECIALTY OR CARELONRX SPECIALTY 10700 WORLD TRADE BLVD STE 110
RALEIGHNC2761704/01/2024  
FQHCLA463CAREMARK TENNESSEE SPECIALTY PHARMACY, LDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 8370 WOLF LAKE DR
STE 107 		BARTLETTTN3813304/01/2024  
FQHCLA463ACAREMARK TENNESSEE SPECIALTY PHARMACY, LDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 8370 WOLF LAKE DR
STE 107 		BARTLETTTN3813304/01/2024  
FQHCLA463ACAREMARK, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1127 BRYN MAWR AVE
SUITE A 		REDLANDSCA9237404/01/2024  
FQHCLA463CAREMARK, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1127 BRYN MAWR AVE
SUITE A 		REDLANDSCA9237404/01/2024  
FQHCLA463CAREMARK, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 7251 S. EASTERN AVE.
LAS VEGASNV8911904/01/2024  
FQHCLA463ACAREMARK, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 7251 S. EASTERN AVE.
LAS VEGASNV8911904/01/2024  
FQHCLA463COORDINATED CARE NETWORKCOORDINATED CARE NETWORK 300 PENN CENTER BLVD STE 405
PITTSBURGHPA15235-551104/01/2025  
FQHCLA463ACOORDINATED CARE NETWORKCOORDINATED CARE NETWORK 300 PENN CENTER BLVD STE 405
PITTSBURGHPA15235-551104/01/2025  
FQHCLA463ACOORDINATED CARE NETWORK PHARMACY249 S 13TH ST
PHILADELPHIAPA1910704/01/2025  
FQHCLA463COORDINATED CARE NETWORK PHARMACY100 N CAMERON ST. STE 201
HARRISBURGPA1710104/01/2025  
FQHCLA463ACOORDINATED CARE NETWORK PHARMACY100 N CAMERON ST. STE 201
HARRISBURGPA1710104/01/2025  
FQHCLA463COORDINATED CARE NETWORK PHARMACY249 S 13TH ST
PHILADELPHIAPA1910704/01/2025  
FQHCLA463CVS CAREMARKDBA CVS/CAREMARK OR CF# 11506 1 GREAT VALLEY BOULEVARD
WILKES BARREPA1870601/01/2025  
FQHCLA463ACVS CAREMARKDBA CVS/CAREMARK OR CF# 11506 1 GREAT VALLEY BOULEVARD
WILKES BARREPA1870601/01/2025  
FQHCLA463ACVS CAREMARK ADVANCED TECHNOLOGY PHARMACDBA CVS/CAREMARK 48067 1780 WALL ST
MT PROSPECTIL6005601/01/2025  
FQHCLA463CVS CAREMARK ADVANCED TECHNOLOGY PHARMACDBA CVS/CAREMARK 48067 1780 WALL ST
MT PROSPECTIL6005601/01/2025  
FQHCLA463ACVS/SPECIALTY OR CARELONRX SPECIALTY PHACAREMARK, LLC 1001 SPINKS ROAD, STE 280
FLOWER MOUNDTX7502804/01/2024  
FQHCLA463CVS/SPECIALTY OR CARELONRX SPECIALTY PHACAREMARK, LLC 1001 SPINKS ROAD, STE 280
FLOWER MOUNDTX7502804/01/2024  
FQHCLA463CYSTIC FIBROSIS SERVICES, LLCDBA WALGREENS SPECIALTY PHARMACY #16280 10530 JOHN W ELLIOTT DR STE 200
FRISCOTX7503304/01/2024 05/24/2024
FQHCLA463ACYSTIC FIBROSIS SERVICES, LLCDBA WALGREENS SPECIALTY PHARMACY #16280 10530 JOHN W ELLIOTT DR STE 200
FRISCOTX7503304/01/2024 05/24/2024
FQHCLA463DELAWARE CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 00088 1005 DELAWARE AVE.
WILMINGTONDE1980610/01/2024  
FQHCLA463ADELAWARE CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 00088 1005 DELAWARE AVE.
WILMINGTONDE1980610/01/2024  
FQHCLA463NEW JERSEY CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 06900 1320 PARKWAY AVE.
EWINGNJ0862810/01/2024  
FQHCLA463NEW JERSEY CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 00809 6815 TILTON ROAD
EGG HARBOR TWPNJ0823410/01/2024  
FQHCLA463ANEW JERSEY CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 00809 6815 TILTON ROAD
EGG HARBOR TWPNJ0823410/01/2024  
FQHCLA463ANEW JERSEY CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 06900 1320 PARKWAY AVE.
EWINGNJ0862810/01/2024  
FQHCLA463AOPTUM FRONTIER THERAPIES II, LLC6425 SANTA MARGARITA ST UNIT 110
LAS VEGASNV89118-191307/01/2024  
FQHCLA463OPTUM FRONTIER THERAPIES II, LLC6425 SANTA MARGARITA ST UNIT 110
LAS VEGASNV89118-191307/01/2024  
FQHCLA463AOPTUM PHARMACY 702, LLC1050 PATROL RD
JEFFERSONVILLEIN4713007/01/2024  
FQHCLA463OPTUM PHARMACY 702, LLC1050 PATROL RD
JEFFERSONVILLEIN4713007/01/2024  
FQHCLA463AOPTUM PHARMACY 706, INC.30-30 47TH AVENUE SUITE 410
LONG ISLAND CITYNY1110107/01/2024  
FQHCLA463OPTUM PHARMACY 706, INC.30-30 47TH AVENUE SUITE 410
LONG ISLAND CITYNY1110107/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02159 2320-26 FAIRMOUNT AVENUE
PHILADELPHIAPA1913010/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02866 1046 MARKET ST.
PHILADELPHIAPA1910710/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.CVS/PHARMACY # 11170 1201 WALNUT ST
PHILADELPHIAPA1910710/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02255 2640 E. CUMBERLAND ST.
PHILADELPHIAPA1912510/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 00771 6150 N 5TH STREET
PHILADELPHIAPA1912010/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 00371 6501 HARBISON AVENUE
PHILADELPHIAPA1914910/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02986 7065 LINCOLN DRIVE
PHILADELPHIAPA1911910/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02222 7520 CITY LINE AVE.
PHILADELPHIAPA1915110/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01193 835 OLD YORK ROAD
JENKINTOWNPA1904610/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 05867 401 SPRING GARDEN ST.
PHILADELPHIAPA1912310/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02120 6344 STENTON AVENUE
PHILADELPHIAPA1913810/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02408 802 N LANSDOWNE AVE
DREXEL HILLPA1902610/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02783 518 PORT ROYAL AVENUE
PHILADELPHIAPA1912810/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01545 1500 SPRUCE STREET
PHILADELPHIAPA1910210/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.CVS/PHARMACY #11371 1717 NORTH 12TH STREET, UNIT F
PHILADELPHIAPA1912210/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01196 7700 GERMANTOWN AVENUE
PHILADELPHIAPA1911810/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02785 1306 MACDADE BLVD.
WOODLYNPA1909410/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02077 1901 WEST OREGON AVENUE
PHILADELPHIAPA1914510/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 00450 3401 WALNUT ST.
PHILADELPHIAPA1910410/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02166 3780 MAIN STREET
PHILADELPHIAPA1912710/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 05726 701 E. KING ST.
SHIPPENSBURGPA1725710/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.CVS/PHARMACY # 11136 314 SOUTH 5TH STREET
PHILADELPHIAPA1910610/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA CVS/PHARMACY #11356 3401 ARAMINGO AVENUE
PHILADELPHIAPA1913410/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.CVS/PHARMACY #11219 1138 N. 2ND STREET
PHILADELPHIAPA1912310/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.CVS PHARMACY # 17207 4000 MONUMENT RD
PHILADELPHIAPA1913110/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 08984 6701 RIDGE AVE.
PHILADELPHIAPA1912810/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 04007 3925 WALNUT ST.
PHILADELPHIAPA1910410/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02121 6601 NORTH BROAD STREET
PHILADELPHIAPA1912610/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 03142 119 E. BALTIMORE AVE.
LANSDOWNEPA1905010/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.CVS/PHARMACY # 11177 490 NORTH BROAD ST, SUITE 100
PHILADELPHIAPA1913010/01/2024 02/12/2025
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01064 1826-30 CHESTNUT STREET
PHILADELPHIAPA1910310/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02755 4314 LOCUST STREET
PHILADELPHIAPA1910410/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.CVS PHARMACY # 16775 1 MIFFLIN ST
PHILADELPHIAPA1914810/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01296 5001 TOWNSHIP LINE ROAD
DREXEL HILLPA1902610/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA CVS/PHARMACY # 10526 259 MARKET ST
PHILADELPHIAPA1910610/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02398 3300-10 SOUTH BROAD STREET
PHILADELPHIAPA1914510/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01913 1405 SOUTH 10TH STREET
PHILADELPHIAPA1914710/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA CVS/PHARMACY # 10090 2132 SOUTH STREET
PHILADELPHIAPA1914610/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02704 4849 MARKET ST.
PHILADELPHIAPA1913910/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 04007 3925 WALNUT ST.
PHILADELPHIAPA1910410/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA CVS/PHARMACY # 10090 2132 SOUTH STREET
PHILADELPHIAPA1914610/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 05867 401 SPRING GARDEN ST.
PHILADELPHIAPA1912310/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01913 1405 SOUTH 10TH STREET
PHILADELPHIAPA1914710/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01064 1826-30 CHESTNUT STREET
PHILADELPHIAPA1910310/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02866 1046 MARKET ST.
PHILADELPHIAPA1910710/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02408 802 N LANSDOWNE AVE
DREXEL HILLPA1902610/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02986 7065 LINCOLN DRIVE
PHILADELPHIAPA1911910/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 00771 6150 N 5TH STREET
PHILADELPHIAPA1912010/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02398 3300-10 SOUTH BROAD STREET
PHILADELPHIAPA1914510/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02255 2640 E. CUMBERLAND ST.
PHILADELPHIAPA1912510/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02783 518 PORT ROYAL AVENUE
PHILADELPHIAPA1912810/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.CVS/PHARMACY # 11136 314 SOUTH 5TH STREET
PHILADELPHIAPA1910610/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 00371 6501 HARBISON AVENUE
PHILADELPHIAPA1914910/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02222 7520 CITY LINE AVE.
PHILADELPHIAPA1915110/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02785 1306 MACDADE BLVD.
WOODLYNPA1909410/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02166 3780 MAIN STREET
PHILADELPHIAPA1912710/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01296 5001 TOWNSHIP LINE ROAD
DREXEL HILLPA1902610/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01545 1500 SPRUCE STREET
PHILADELPHIAPA1910210/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.CVS/PHARMACY #11219 1138 N. 2ND STREET
PHILADELPHIAPA1912310/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.CVS/PHARMACY #11371 1717 NORTH 12TH STREET, UNIT F
PHILADELPHIAPA1912210/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02077 1901 WEST OREGON AVENUE
PHILADELPHIAPA1914510/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02121 6601 NORTH BROAD STREET
PHILADELPHIAPA1912610/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02704 4849 MARKET ST.
PHILADELPHIAPA1913910/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01196 7700 GERMANTOWN AVENUE
PHILADELPHIAPA1911810/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.CVS PHARMACY # 16775 1 MIFFLIN ST
PHILADELPHIAPA1914810/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02120 6344 STENTON AVENUE
PHILADELPHIAPA1913810/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02159 2320-26 FAIRMOUNT AVENUE
PHILADELPHIAPA1913010/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.CVS/PHARMACY # 11177 490 NORTH BROAD ST, SUITE 100
PHILADELPHIAPA1913010/01/2024 02/12/2025
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02755 4314 LOCUST STREET
PHILADELPHIAPA1910410/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01193 835 OLD YORK ROAD
JENKINTOWNPA1904610/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.CVS PHARMACY # 17207 4000 MONUMENT RD
PHILADELPHIAPA1913110/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.CVS/PHARMACY # 11170 1201 WALNUT ST
PHILADELPHIAPA1910710/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 08984 6701 RIDGE AVE.
PHILADELPHIAPA1912810/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA CVS/PHARMACY #11356 3401 ARAMINGO AVENUE
PHILADELPHIAPA1913410/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 00450 3401 WALNUT ST.
PHILADELPHIAPA1910410/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA CVS/PHARMACY # 10526 259 MARKET ST
PHILADELPHIAPA1910610/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 05726 701 E. KING ST.
SHIPPENSBURGPA1725710/01/2024  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 03142 119 E. BALTIMORE AVE.
LANSDOWNEPA1905010/01/2024  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.CVS/PHARMACY # 10459 1919 MARKET ST. SUITE 150
PHILADELPHIAPA1910304/01/2025  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.CVS/PHARMACY # 10459 1919 MARKET ST. SUITE 150
PHILADELPHIAPA1910304/01/2025  
FQHCLA463APENNSYLVANIA CVS PHARMACY, L.L.C.CVS PHARMACY # 17252 600 HATTON DR
GLEN MILLSPA1934204/01/2025  
FQHCLA463PENNSYLVANIA CVS PHARMACY, L.L.C.CVS PHARMACY # 17252 600 HATTON DR
GLEN MILLSPA1934204/01/2025  
FQHCLA463PROCARE PHARMACY DIRECT, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 105 MALL BOULEVARD
MONROEVILLEPA1514604/01/2024  
FQHCLA463APROCARE PHARMACY DIRECT, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 105 MALL BOULEVARD
MONROEVILLEPA1514604/01/2024  
FQHCLA463APROCARE PHARMACY, L.L.C.DBA CVS/PHARMACY #2923 3250 HARDEN ST. EXT. SUITE #300
COLUMBIASC2920304/01/2024  
FQHCLA463APROCARE PHARMACY, L.L.C.DBA CVS/PHARMACY # 02553 1117 WALNUT ST.
PHILADELPHIAPA1910704/01/2024  
FQHCLA463PROCARE PHARMACY, L.L.C.DBA CVS/PHARMACY #2923 3250 HARDEN ST. EXT. SUITE #300
COLUMBIASC2920304/01/2024  
FQHCLA463PROCARE PHARMACY, L.L.C.DBA CVS/PHARMACY # 02553 1117 WALNUT ST.
PHILADELPHIAPA1910704/01/2024  
FQHCLA463PROCARE PHARMACY, L.L.C.DBA: CVS/PHARMACY #2909 1521 4TH AVE., SOUTH
BIRMINGHAMAL3523304/01/2024  
FQHCLA463APROCARE PHARMACY, L.L.C.DBA: CVS/PHARMACY #2909 1521 4TH AVE., SOUTH
BIRMINGHAMAL3523304/01/2024  
FQHCLA463WALGREEN EASTERN CO INCDBA: WALGREENS # 04115 4201 N BROAD ST
PHILADELPHIAPA1914004/01/2024 01/30/2025
FQHCLA463AWALGREEN EASTERN CO INCDBA: WALGREENS # 04115 4201 N BROAD ST
PHILADELPHIAPA1914004/01/2024 01/30/2025
FQHCLA463WALGREEN EASTERN CO. INC.DBA:WALGREENS #15336 1 SOUTH BROAD STREET
PHILADELPHIAPA1910704/01/2024 05/24/2024
FQHCLA463AWALGREEN EASTERN CO. INC.DBA:WALGREENS #15336 1 SOUTH BROAD STREET
PHILADELPHIAPA1910704/01/2024 05/24/2024
FQHCLA463WALGREEN EASTERN CO., INC.DBA: WALGREENS 8828 FRANKFORD AVE.
PHILADELPHIAPA1913604/01/2024  
FQHCLA463AWALGREEN EASTERN CO., INC.DBA: WALGREENS # 04429 150 N MACDADE BLVD.
GLENOLDENPA1903604/01/2024  
FQHCLA463WALGREEN EASTERN CO., INC.DBA: WALGREENS # 07543 2310 W OREGON AVE
PHILADELPHIAPA19145-412204/01/2024  
FQHCLA463WALGREEN EASTERN CO., INC.DBA: WALGREENS # 05522 1607 BRIDGE ST
PHILADELPHIAPA1912404/01/2024 05/24/2024
FQHCLA463WALGREEN EASTERN CO., INC.DBA: WALGREENS # 04429 150 N MACDADE BLVD.
GLENOLDENPA1903604/01/2024  
FQHCLA463AWALGREEN EASTERN CO., INC.DBA: WALGREENS # 05522 1607 BRIDGE ST
PHILADELPHIAPA1912404/01/2024 05/24/2024
FQHCLA463AWALGREEN EASTERN CO., INC.DBA WALGREENS SPECIALTY PHARMACY #15316 1227 LOCUST ST
PHILADELPHIAPA1910704/01/2024  
FQHCLA463WALGREEN EASTERN CO., INC.DBA: WALGREENS # 06367 1809 E ALLEGHENY AVE
PHILADELPHIAPA1913404/01/2024 05/24/2024
FQHCLA463AWALGREEN EASTERN CO., INC.DBA: WALGREENS # 04926 7001 FRANKFORD AVE
PHILADELPHIAPA1913504/01/2024  
FQHCLA463AWALGREEN EASTERN CO., INC.DBA: WALGREENS # 03791 2014-24 S BROAD ST
PHILADELPHIAPA1914504/01/2024 11/12/2024
FQHCLA463AWALGREEN EASTERN CO., INC.DBA: WALGREENS #11780 2655 SOUTH TENTH ST.
PHILADELPHIAPA1914804/01/2024 05/24/2024
FQHCLA463WALGREEN EASTERN CO., INC.DBA WALGREENS SPECIALTY PHARMACY #15316 1227 LOCUST ST
PHILADELPHIAPA1910704/01/2024  
FQHCLA463AWALGREEN EASTERN CO., INC.DBA: WALGREENS # 06367 1809 E ALLEGHENY AVE
PHILADELPHIAPA1913404/01/2024 05/24/2024
FQHCLA463AWALGREEN EASTERN CO., INC.DBA: WALGREENS # 07336 1617 JOHN F KENNEDY BLVD LBBY W8
PHILADELPHIAPA1910304/01/2024  
FQHCLA463WALGREEN EASTERN CO., INC.DBA: WALGREENS 1800 SOUTH ST.
PHILADELPHIAPA1914604/01/2024  
FQHCLA463WALGREEN EASTERN CO., INC.DBA: WALGREENS # 04926 7001 FRANKFORD AVE
PHILADELPHIAPA1913504/01/2024  
FQHCLA463WALGREEN EASTERN CO., INC.DBA: WALGREENS 1101 LOCUST ST.
PHILADELPHIAPA1910704/01/2024 01/29/2025
FQHCLA463AWALGREEN EASTERN CO., INC.DBA: WALGREENS 1101 LOCUST ST.
PHILADELPHIAPA1910704/01/2024 01/29/2025
FQHCLA463AWALGREEN EASTERN CO., INC.DBA WALGREENS SPECIALTY PHARMACY #16519 1334 BAINBRIDGE ST
PHILADELPHIAPA1914704/01/2024  
FQHCLA463AWALGREEN EASTERN CO., INC.DBA: WALGREENS # 07543 2310 W OREGON AVE
PHILADELPHIAPA19145-412204/01/2024  
FQHCLA463AWALGREEN EASTERN CO., INC.DBA: WALGREENS 1800 SOUTH ST.
PHILADELPHIAPA1914604/01/2024  
FQHCLA463WALGREEN EASTERN CO., INC.DBA: WALGREENS #11780 2655 SOUTH TENTH ST.
PHILADELPHIAPA1914804/01/2024 05/24/2024
FQHCLA463AWALGREEN EASTERN CO., INC.DBA: WALGREENS 300 N. 63RD ST.
PHILADELPHIAPA1913904/01/2024 03/21/2025
FQHCLA463WALGREEN EASTERN CO., INC.DBA WALGREENS SPECIALTY PHARMACY #16519 1334 BAINBRIDGE ST
PHILADELPHIAPA1914704/01/2024  
FQHCLA463WALGREEN EASTERN CO., INC.DBA: WALGREENS # 03791 2014-24 S BROAD ST
PHILADELPHIAPA1914504/01/2024 11/12/2024
FQHCLA463AWALGREEN EASTERN CO., INC.DBA: WALGREENS 8828 FRANKFORD AVE.
PHILADELPHIAPA1913604/01/2024  
FQHCLA463WALGREEN EASTERN CO., INC.DBA: WALGREENS # 07336 1617 JOHN F KENNEDY BLVD LBBY W8
PHILADELPHIAPA1910304/01/2024  
FQHCLA463WALGREEN EASTERN CO., INC.DBA: WALGREENS # 07224 119 E DEKALB PIKE
KING OF PRUSSIAPA1940604/01/2024  
FQHCLA463WALGREEN EASTERN CO., INC.DBA: WALGREENS 300 N. 63RD ST.
PHILADELPHIAPA1913904/01/2024 01/21/2025
FQHCLA463AWALGREEN EASTERN CO., INC.DBA: WALGREENS # 07224 119 E DEKALB PIKE
KING OF PRUSSIAPA1940604/01/2024  
FQHCLA463AWALGREENS SPECIALTY PHARMACY, LLCDBA WALGREENS SPECIALTY PHARMACY #16287 130 ENTERPRISE DR
PITTSBURGHPA1527504/01/2024  
FQHCLA463WALGREENS SPECIALTY PHARMACY, LLCDBA WALGREENS SPECIALTY PHARMACY #16287 130 ENTERPRISE DR
PITTSBURGHPA1527504/01/2024  
FQHCLA463WALGREENS SPECIALTY PHARMACY, LLCDBA WALGREENS SPECIALTY PHARMACY #15438 41460 HAGGERTY CIR S
CANTONMI4818804/01/2024 05/24/2024
FQHCLA463AWALGREENS SPECIALTY PHARMACY, LLCDBA WALGREENS SPECIALTY PHARMACY #15438 41460 HAGGERTY CIR S
CANTONMI4818804/01/2024 05/24/2024
FQHCLA463WALGREENS SPECIALTY PHARMACY, LLCDBA WALGREENS SPECIALTY PHARMACY #15443 10530 JOHN W ELLIOTT DR STE 100
FRISCOTX7503304/01/2024 05/24/2024
FQHCLA463AWALGREENS SPECIALTY PHARMACY, LLCDBA WALGREENS SPECIALTY PHARMACY #15443 10530 JOHN W ELLIOTT DR STE 100
FRISCOTX7503304/01/2024 05/24/2024
History
SectionFieldActionActivityValue BeforeValue AfterTimestamp 
DetailsLast Recertification DateUpdateRecertification 2/17/2025 11:27:40 AM2/17/2025 11:27 AM
DetailsStateUpdate ApprovedActive4/1/2024 12:01 AM
ContactsSigned ByInsertNew Registration Manley, Alecia Executive Operating Officer Mazzoni Center 21556306523/11/2024 12:45 PM
Details340B IDUpdateNew Registration FQHCLA463A3/11/2024 12:45 PM
DatesParticipating Approval DateUpdateNew Registration 3/11/2024 12:45:59 PM3/11/2024 12:45 PM
DetailsStateUpdateNew RegistrationPendingApproved3/11/2024 12:45 PM
DatesSigned By DateUpdateNew Registration 1/8/2024 9:48:46 AM3/11/2024 12:45 PM
DatesStart DateUpdateNew Registration 4/1/2024 12:00:00 AM3/11/2024 12:45 PM
AddressesMain AddressInsertNew Registration  1348 Bainbridge St Philadelphia, PA 19147-18101/5/2024 11:12 AM
ContactsAuthorizing OfficialInsertNew Registration Manley, Alecia Executive Operating Officer Mazzoni Center 21556306521/5/2024 11:12 AM
ContactsPrimary ContactInsertNew Registration Canavin, Valerie Compliance Director Mazzoni Center 21556306521/5/2024 11:12 AM
DetailsAssistance Received From DateInsertNew Registration  1/5/2024 11:12 AM
DetailsAssistance Received To DateInsertNew Registration  1/5/2024 11:12 AM
DetailsLast Recertification DateInsertNew Registration  1/5/2024 11:12 AM
DetailsGrant NumberInsertNew Registration LALCS529651/5/2024 11:12 AM
Details340B IDInsertNew Registration  1/5/2024 11:12 AM
DetailsIs Authorizing Official EHB DataInsertNew Registration  1/5/2024 11:12 AM
DatesLast Date That 340B Drugs PurchasedInsertNew Registration  1/5/2024 11:12 AM
DetailsMedicare Provider NumberInsertNew Registration  1/5/2024 11:12 AM
DetailsEntity NameInsertNew Registration Mazzoni Center1/5/2024 11:12 AM
DetailsNOFO NumberInsertNew Registration  1/5/2024 11:12 AM
DetailsProgram CodeInsertNew Registration FQHCLA1/5/2024 11:12 AM
DetailsEntity SubnameInsertNew Registration Bainbridge1/5/2024 11:12 AM
DatesParticipating Approval DateInsertNew Registration  1/5/2024 11:12 AM
DetailsStateInsertNew Registration Pending1/5/2024 11:12 AM
DatesRegistration DateInsertNew Registration 1/5/2024 11:12:19 AM1/5/2024 11:12 AM
DatesSigned By DateInsertNew Registration  1/5/2024 11:12 AM
DatesStart DateInsertNew Registration  1/5/2024 11:12 AM
TerminationsTermination CommentsInsertNew Registration  1/5/2024 11:12 AM
TerminationsTermination DateInsertNew Registration  1/5/2024 11:12 AM
TerminationsTermination Effective DateInsertNew Registration  1/5/2024 11:12 AM
TerminationsTermination ReasonInsertNew Registration  1/5/2024 11:12 AM