Covered Entity Details

DSH030111AB Banner – University Medical Center South (Approved) - information as of 4/28/2025 1:42:52 AM

Main Details

Name

Banner – University Medical Center South

Subdivision Name

BANNER UNIVERSITY MEDICINE MULTISPECIALTY SERVICES (OBGYN) - OBGYN

Type

Disproportionate Share Hospital

Rural

340B ID

DSH030111AB

Medicare Provider Number

030111

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/8/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/15/2025

Last Recertification Date

Contacts

Authorizing Official

Banner Health
Meiko Onken, Chief Operating Officer
(602) 625-2651

Primary Contact

Banner University Medical Center Tucson
Kurt Weibel, Director of Pharmacy Services
(520) 694-6061

Addresses

Street Address

2800 E AJO WAY
100
TUCSON, AZ 85713

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	005638,988451	1558759498,1801284617,1508809427

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
DSH030111A	Child	DSH	Banner – University Medical Center South	Arizona Institute for Sports Medicine	2800 E. Ajo Way, Suite 200	Tucson	AZ	Active
DSH030111AA	Child	DSH	Banner – University Medical Center South	PBC-Pain Mgmt-Clinic	707 N Alvernon Way	Tucson	AZ	Terminated
DSH030111AB	Child	DSH	Banner – University Medical Center South	BANNER UNIVERSITY MEDICINE MULTISPECIALTY SERVICES (OBGYN) - OBGYN	2800 E AJO WAY	TUCSON	AZ	Approved
DSH030111B	Child	DSH	Banner – University Medical Center South	Adult Health Services	2800 E. Ajo Way, Suite 104	Tucson	AZ	Terminated
DSH030111D	Child	DSH	Banner – University Medical Center South	Family Medicine Clinic	3950 S. Country Club Road, Suite 130	Tucson	AZ	Terminated
DSH030111E	Child	DSH	Banner – University Medical Center South	Multi-Specialty Clinic	2800 E. Ajo Way, Suite 102	Tucson	AZ	Terminated
DSH030111F	Child	DSH	Banner – University Medical Center South	Surgical Specialties Clinic	2800 E. Ajo Way, Suite 100	Tucson	AZ	Terminated
DSH030111G	Child	DSH	Banner – University Medical Center South	Neurology Clinic	2800 E. Ajo Way, Suite 105	Tucson	AZ	Terminated
DSH030111H	Child	DSH	Banner – University Medical Center South	Infusion Clinic	2800 E Ajo Way	Tucson	AZ	Terminated
DSH030111J	Child	DSH	Banner – University Medical Center South	Rheumatology Clinic	2800 E Ajo Way	Tucson	AZ	Terminated
DSH030111K	Child	DSH	Banner – University Medical Center South	PBC-FP Alvernon-Clinic	707 N Alvernon Way	Tucson	AZ	Active
DSH030111L	Child	DSH	Banner - University Medical Center South	Alvernon Ophthamology and Optometry	707 N. Alvernon, Suite 301	Tucson	AZ	Terminated
DSH030111M	Child	DSH	Banner – University Medical Center South	Psychiatry Clinic	2800 E. Ajo Way, Suites P1241/P3300	Tucson	AZ	Terminated
DSH030111N	Child	DSH	Banner – University Medical Center South	Alvernon Multi-specialty Clinic (Clinic - 2nd floor Alvernon)	707 N Alvernon Way	Tucson	AZ	ToBeTerminated
DSH030111P	Child	DSH	Banner – University Medical Center South	Diabetes Clinic	3950 S. Country Club Road	Tucson	AZ	Terminated
DSH030111Q	Child	DSH	Banner – University Medical Center South	Clinic - Ajo Surgery - PBC SC- Corridor Surgery (ENT)	2800 E Ajo Way	Tucson	AZ	Terminated
DSH030111R	Child	DSH	Banner – University Medical Center South	Clinic - 2nd Floor Alvernon - PBC-Gen Surg Alvernon-Clinic	707 N Alvernon Way	Tucson	AZ	Terminated
DSH030111S	Child	DSH	Banner – University Medical Center South	Clinic - Ajo OB/GYN - PBC-OB/Gyn-Clinic	2800 E Ajo Way	Tucson	AZ	Terminated
DSH030111T	Child	DSH	Banner – University Medical Center South	Clinic - Alvernon - PBC Alvernon-Geriatric Clinic	707 N Alvernon Way	Tucson	AZ	Terminated
DSH030111U	Child	DSH	Banner – University Medical Center South	Clinic - Ajo Neuro - PBC-Neuro EMG- Clinic	2800 E Ajo Way	Tucson	AZ	Terminated
DSH030111V	Child	DSH	Banner – University Medical Center South	Clinic - Ajo Medicine - PBC-Nephrology-Clinic	2800 E Ajo Way	Tucson	AZ	Terminated
DSH030111W	Child	DSH	Banner – University Medical Center South	Clinic - Ajo OB/GYN - PBC SC-Corridor Surg(Podiatry)	2800 E Ajo Way	Tucson	AZ	Terminated
DSH030111X	Child	DSH	Banner – University Medical Center South	Clinic - Ajo OB/GYN - PBC SC-Corridor Surg(Gen Surg)	2800 E Ajo Way	Tucson	AZ	Terminated
DSH030111Y	Child	DSH	Banner – University Medical Center South	Clinic - Alvernon - PBC Alvernon-Intgrtiv Med-Clin	707 N Alvernon Way	Tucson	AZ	Terminated
DSH030111Z	Child	DSH	Banner – University Medical Center South	Clinic - Ajo Cardiology - PBC-Cardiology 2nd Floor-Clinic	2800 E Ajo Way	Tucson	AZ	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Onken, Meiko Chief Operating Officer Banner Health 6026252651	4/15/2025 8:26 AM
Details	340B ID	Update	New Registration		DSH030111AB	4/15/2025 8:26 AM
Details	Entity Name	Update	New Registration	BANNER UNIVERSITY MED CENTER SOUTH	Banner – University Medical Center South	4/15/2025 8:26 AM
Details	Entity Subname	Update	New Registration	BANNER UNIVERSITY MEDICINE MULTISPECIALTY SERVICES (OBGYN)	BANNER UNIVERSITY MEDICINE MULTISPECIALTY SERVICES (OBGYN) - OBGYN	4/15/2025 8:26 AM
Dates	Participating Approval Date	Update	New Registration		4/15/2025 8:26:59 AM	4/15/2025 8:26 AM
Details	State	Update	New Registration	Pending	Approved	4/15/2025 8:26 AM
Dates	Signed By Date	Update	New Registration		4/10/2025 10:17:43 AM	4/15/2025 8:26 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/15/2025 8:26 AM
Addresses	Main Address	Insert	New Registration		2800 E AJO WAY 100 TUCSON, AZ 85713	4/8/2025 3:51 PM
Addresses	Billing Address	Insert	New Registration		Banner Health Accounts Payable PO Box 2977 Phoenix, AZ 85062	4/8/2025 3:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2025 3:51 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		005638	4/8/2025 3:51 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	4/8/2025 3:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2025 3:51 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		988451	4/8/2025 3:51 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	4/8/2025 3:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1558759498	4/8/2025 3:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/8/2025 3:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801284617	4/8/2025 3:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/8/2025 3:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1508809427	4/8/2025 3:51 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/8/2025 3:51 PM
Contacts	Primary Contact	Insert	New Registration		Weibel, Kurt Director of Pharmacy Services Banner University Medical Center Tucson 5206946061	4/8/2025 3:51 PM
Contacts	Authorizing Official	Insert	New Registration		Onken, Meiko Chief Operating Officer Banner Health 6026252651	4/8/2025 3:51 PM
Details	Assistance Received From Date	Insert	New Registration			4/8/2025 3:51 PM
Details	Assistance Received To Date	Insert	New Registration			4/8/2025 3:51 PM
Details	Last Recertification Date	Insert	New Registration			4/8/2025 3:51 PM
Details	Grant Number	Insert	New Registration			4/8/2025 3:51 PM
Details	340B ID	Insert	New Registration			4/8/2025 3:51 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/8/2025 3:51 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/8/2025 3:51 PM
Details	Medicare Provider Number	Insert	New Registration		030111	4/8/2025 3:51 PM
Details	Entity Name	Insert	New Registration		BANNER UNIVERSITY MED CENTER SOUTH	4/8/2025 3:51 PM
Details	NOFO Number	Insert	New Registration			4/8/2025 3:51 PM
Details	Program Code	Insert	New Registration		DSH	4/8/2025 3:51 PM
Details	Entity Subname	Insert	New Registration		BANNER UNIVERSITY MEDICINE MULTISPECIALTY SERVICES (OBGYN)	4/8/2025 3:51 PM
Dates	Participating Approval Date	Insert	New Registration			4/8/2025 3:51 PM
Details	State	Insert	New Registration		Pending	4/8/2025 3:51 PM
Dates	Registration Date	Insert	New Registration		4/8/2025 3:51:36 PM	4/8/2025 3:51 PM
Dates	Signed By Date	Insert	New Registration			4/8/2025 3:51 PM
Dates	Start Date	Insert	New Registration			4/8/2025 3:51 PM
Terminations	Termination Comments	Insert	New Registration			4/8/2025 3:51 PM
Terminations	Termination Date	Insert	New Registration			4/8/2025 3:51 PM
Terminations	Termination Effective Date	Insert	New Registration			4/8/2025 3:51 PM
Terminations	Termination Reason	Insert	New Registration			4/8/2025 3:51 PM