Covered Entity Details

DSH030016D Banner Casa Grande Medical Center (Active) - information as of 5/27/2025 2:44:02 PM

Main Details

Name

Banner Casa Grande Medical Center

Subdivision Name

BANNER MEDCARE CLINIC - C/P- Coumadin Clinic

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH030016D

Medicare Provider Number

030016

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/11/2024

Participating Start Date

1/1/2025

Participating Approval Date

10/21/2024

Last Recertification Date

Contacts

Authorizing Official

Banner Casa Grande Medical Center
Louis Schroeder, Chief Financial Officer
(520) 381-6529

Primary Contact

Banner Casa Grande Medical Center
Pamella L Martin, Director of Pharmacy
(520) 381-6506

Addresses

Street Address

1828 E FLORENCE BLVD
BLDG A
115
CASA GRANDE, AZ 85122

Billing Address

BANNER HEALTH ACCOUNTS PAYABLE
PO BOX 2977
PHOENIX, AZ 85062

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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
AZ	916171	1003232976

Shipping Addresses

Same as Street Address

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.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH030016B	Child	DSH	Banner Casa Grande Medical Center	DESERT REFLECTIONS IMAGING CENTER	1828 E FLORENCE BLVD BLDG B STE 118	CASA GRANDE	AZ	Terminated
DSH030016C	Child	DSH	Banner Casa Grande Medical Center	Banner Casa Grande Coumadin Clinic	1676 E. McMurray Boulevard, Suite 3	Casa Grande	AZ	Terminated
DSH030016D	Child	DSH	Banner Casa Grande Medical Center	BANNER MEDCARE CLINIC - C/P- Coumadin Clinic	1828 E FLORENCE BLVD	CASA GRANDE	AZ	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	1/1/2025 12:01 AM
Addresses	Billing Address	Insert	New Registration		BANNER HEALTH ACCOUNTS PAYABLE PO BOX 2977 PHOENIX, AZ 85062	10/21/2024 8:18 AM
Contacts	Signed By	Insert	New Registration		Schroeder, Louis Chief Financial Officer Banner Casa Grande Medical Center 5203816529	10/21/2024 8:18 AM
Details	340B ID	Update	New Registration		DSH030016D	10/21/2024 8:18 AM
Details	Entity Name	Update	New Registration	BANNER CASA GRANDE MEDICAL CENTER	Banner Casa Grande Medical Center	10/21/2024 8:18 AM
Details	Entity Subname	Update	New Registration	BANNER MEDCARE CLINIC	BANNER MEDCARE CLINIC - C/P- Coumadin Clinic	10/21/2024 8:18 AM
Dates	Participating Approval Date	Update	New Registration		10/21/2024 8:18:51 AM	10/21/2024 8:18 AM
Details	State	Update	New Registration	Pending	Approved	10/21/2024 8:18 AM
Dates	Signed By Date	Update	New Registration		10/18/2024 10:52:36 AM	10/21/2024 8:18 AM
Dates	Start Date	Update	New Registration		1/1/2025 12:00:00 AM	10/21/2024 8:18 AM
Addresses	Billing Address	Insert	New Registration		BANNER HEALTH ACCOUNTS PAYABLE PO BOX 2977 PHOENIX, AZ 85062	10/18/2024 10:52 AM
Addresses	Main Address	Insert	New Registration		1828 E FLORENCE BLVD BLDG A 115 CASA GRANDE, AZ 85122	10/11/2024 12:50 PM
Addresses	Billing Address	Insert	New Registration		BANNER HEALTH ACCOUNTS PAYABLE PO BOX 2977 PHOENIX, AZ 85062	10/11/2024 12:50 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/11/2024 12:50 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		916171	10/11/2024 12:50 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	10/11/2024 12:50 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1003232976	10/11/2024 12:50 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	10/11/2024 12:50 PM
Contacts	Authorizing Official	Insert	New Registration		Schroeder, Louis Chief Financial Officer Banner Casa Grande Medical Center 5203816529	10/11/2024 12:50 PM
Contacts	Primary Contact	Insert	New Registration		Martin, Pamella L Director of Pharmacy Banner Casa Grande Medical Center 5203816506	10/11/2024 12:50 PM
Details	Assistance Received From Date	Insert	New Registration			10/11/2024 12:50 PM
Details	Assistance Received To Date	Insert	New Registration			10/11/2024 12:50 PM
Details	Last Recertification Date	Insert	New Registration			10/11/2024 12:50 PM
Details	Grant Number	Insert	New Registration			10/11/2024 12:50 PM
Details	340B ID	Insert	New Registration			10/11/2024 12:50 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/11/2024 12:50 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/11/2024 12:50 PM
Details	Medicare Provider Number	Insert	New Registration		030016	10/11/2024 12:50 PM
Details	Entity Name	Insert	New Registration		BANNER CASA GRANDE MEDICAL CENTER	10/11/2024 12:50 PM
Details	NOFO Number	Insert	New Registration			10/11/2024 12:50 PM
Details	Program Code	Insert	New Registration		DSH	10/11/2024 12:50 PM
Details	Entity Subname	Insert	New Registration		BANNER MEDCARE CLINIC	10/11/2024 12:50 PM
Dates	Participating Approval Date	Insert	New Registration			10/11/2024 12:50 PM
Details	State	Insert	New Registration		Pending	10/11/2024 12:50 PM
Dates	Registration Date	Insert	New Registration		10/11/2024 12:50:14 PM	10/11/2024 12:50 PM
Dates	Signed By Date	Insert	New Registration			10/11/2024 12:50 PM
Dates	Start Date	Insert	New Registration			10/11/2024 12:50 PM
Terminations	Termination Comments	Insert	New Registration			10/11/2024 12:50 PM
Terminations	Termination Date	Insert	New Registration			10/11/2024 12:50 PM
Terminations	Termination Effective Date	Insert	New Registration			10/11/2024 12:50 PM
Terminations	Termination Reason	Insert	New Registration			10/11/2024 12:50 PM