Covered Entity Details

PED033302-00 PHOENIX CHILDREN'S HOSPITAL (Active) - information as of 6/12/2025 6:05:34 AM

Main Details

Name

PHOENIX CHILDREN'S HOSPITAL

Subdivision Name

Type

Children's Hospital

Rural

340B ID

PED033302-00

Medicare Provider Number

033302

Additional Details

Current Program Status

Active

Registration Date

3/25/2010

Participating Start Date

4/1/2010

Participating Approval Date

3/26/2010

Last Recertification Date

9/19/2024

Contacts

Authorizing Official

Phoenix Children's Hospital
Michelle Bruhn, Executive Vice President & Chief Financial Officer
(602) 933-0221

Primary Contact

Phoenix Children's Hospital
Syed Jaffery, Director of Pharmacy Business Operations
(602) 933-5185

Addresses

Street Address

1919 E THOMAS ROAD
PHOENIX, AZ 85016

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
4/12/12 ADDED SHIP ADD 2; 1/10/12 ADDED SHIP-TO ADD	04/12/2012
1/10/12 ADDED SHIP-TO ADD	01/10/2012

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
No

Shipping Addresses

Shipping Address 1

Safecor Health, LLC
4060 Business Park Dr.
Columbus, OH 43204

Shipping Address 2

PHOENIX CHILDREN'S HOSPITAL - ARROWHEAD (Compounding Pharmacy)
19007 N 67TH AVE
GLENDALE, AZ 85308

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/13/2016	07/01/2016		07/26/2017
Contract Detail	ACCREDO HEALTH GROUP INC	201 GREAT CIRCLE ROAD		NASHVILLE	TN	37228	04/13/2016	07/01/2016	04/01/2024	04/12/2024
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/13/2016	07/01/2016		07/26/2017
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/25/2017	07/01/2017		07/26/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	04/13/2016	07/01/2016		07/26/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/13/2016	07/01/2016	04/01/2024	04/12/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/13/2016	07/01/2016		07/26/2017
Contract Detail	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09202	4742 E. INDIAN SCHOOL	PHOENIX	AZ	85018	04/12/2024	07/01/2024		07/01/2024
Contract Detail	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09314	3440 WEST GLENDALE AVE	PHOENIX	AZ	85051	04/12/2024	07/01/2024		07/01/2024
Contract Detail	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	10/29/2015	01/01/2016	12/26/2018	02/16/2019
Contract Detail	AVELLA OF DEER VALLEY, INC. #38	DBA AVELLA SPECIALTY PHARMACY	24416 N. 19TH AVE	PHOENIX	AZ	85085	02/24/2017	04/01/2017	12/26/2018	02/22/2019
Contract Detail	AVELLA OF PHOENIX III	1101 N CENTRAL AVE., STE. 102		PHOENIX	AZ	85004	10/29/2015	01/01/2016	12/26/2018	02/16/2019
Contract Detail	AVELLA OF SCOTTSDALE	9777 N 91ST ST #C102		SCOTTSDALE	AZ	85258	10/29/2015	01/01/2016	12/26/2018	02/16/2019
Contract Detail	BRIOVARX OF MAINE INC	DBA BRIOVARX	53 DARLING AVE	SOUTH PORTLAND	ME	04106	07/16/2018	10/01/2018	10/01/2019	07/01/2020
Contract Detail	BRIOVARX OF MASSACHUSETTS, LLC	D/B/A BRIOVARX	BLDG 2 - UNIT A 145 BODWELL STREET	AVON	MA	02322	07/16/2018	10/01/2018	10/01/2019	07/01/2020
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/12/2024	07/01/2024		07/01/2024
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/12/2024	07/01/2024		07/01/2024
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/12/2024	07/01/2024		07/01/2024
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/12/2024	07/01/2024		07/01/2024
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/12/2024	07/01/2024		07/01/2024
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	04/12/2024	07/01/2024		07/01/2024
Contract Detail	CVS GILBERT 3272, L.L.C.	DBA: CVS/PHARMACY # 03272	2371 E. GUADALUPE RD.	GILBERT	AZ	85234	04/12/2024	07/01/2024		07/01/2024
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	04/12/2024	07/01/2024		07/01/2024
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	07/14/2021	10/01/2021		10/01/2021
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	07/14/2021	10/01/2021	10/01/2022	10/06/2022
Contract Detail	GERMAN DOBSON CVS, L.L.C.	CVS PHARMACY # 17312	16806 N 7TH ST	PHOENIX	AZ	85022	04/12/2024	07/01/2024		07/01/2024
Contract Detail	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 07852	28138 N. TATUM BLVD.	CAVE CREEK	AZ	85331	04/12/2024	07/01/2024		07/01/2024
Contract Detail	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05892	5050 W. BASELINE RD.	LAVEEN	AZ	85339	04/12/2024	07/01/2024		07/01/2024
Contract Detail	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05038	2010 S. DOBSON RD.	CHANDLER	AZ	85286	04/12/2024	07/01/2024		07/01/2024
Contract Detail	GERMAN DOBSON CVS, L.L.C.	DBA CVS/PHARMACY #2372	3975 E THUNDERBIRD ROAD	PHOENIX	AZ	85032	04/12/2024	07/01/2024		07/01/2024
Contract Detail	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 01720	21201 EAST OCOTILLO RD.,	QUEEN CREEK	AZ	85142	04/12/2024	07/01/2024		07/01/2024
Contract Detail	GERMAN DOBSON CVS, L.L.C.	CVS/PHARMACY # 10615	5450 W HAPPY VALLEY RD	GLENDALE	AZ	85310	04/12/2024	07/01/2024		07/01/2024
Contract Detail	GERMAN DOBSON CVS, L.L.C.	CVS PHARMACY # 17429	21398 S ELLSWORTH LOOP RD	QUEEN CREEK	AZ	85142	04/12/2024	07/01/2024		07/01/2024
Contract Detail	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 09222	4275 W. THOMAS RD.	PHOENIX	AZ	85019	04/12/2024	07/01/2024		07/01/2024
Contract Detail	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 00017	18591 N 59TH AVE	GLENDALE	AZ	85308	04/12/2024	07/01/2024		07/01/2024
Contract Detail	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05794	9069 W. LAKE PLEASANT PKWY.	PEORIA	AZ	85382	04/12/2024	07/01/2024		07/01/2024
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	07/16/2018	10/01/2018		10/01/2018
Contract Detail	OPTUM FRONTIER THERAPIES, LLC	325 W ATHERTON RD	SUITE 1	FLINT	MI	48507-2601	07/17/2023	10/01/2023		10/01/2023
Contract Detail	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	04/15/2021	07/01/2021		07/01/2021
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/15/2022	04/18/2022		04/28/2022
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	07/16/2018	10/01/2018		10/01/2018
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	07/16/2018	10/01/2018		10/01/2018
Contract Detail	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	04/15/2021	07/01/2021		07/01/2021
Contract Detail	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	07/16/2018	10/01/2018	04/09/2021	04/15/2021
Contract Detail	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	04/15/2021	07/01/2021		07/01/2021
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	04/15/2021	07/01/2021		07/01/2021
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	07/14/2021	10/01/2021	10/01/2022	10/06/2022
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/12/2024	07/01/2024		07/01/2024
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #3129	1002 EAST MCDOWELL ROAD	PHOENIX	AZ	85006	04/12/2024	07/01/2024		07/01/2024
Contract Detail	ST JOSEPH'S MCAULEY PHARMACY	500 W. THOMAS ROAD	SUITE 190	PHOENIX	AZ	85013	07/14/2020	10/01/2020		10/01/2020
Contract Detail	WALGREEN ARIZONA DRUG CO	DBA: WALGREENS #10111	3434 W. SOUTHERN AVE	PHOENIX	AZ	85041	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO	DBA: WALGREENS #11116	21212 E OCOTILLO RD	QUEEN CREEK	AZ	85142	07/14/2021	10/01/2021		10/01/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 01272	5101 WEST INDIAN SCHOOL	PHOENIX	AZ	85031	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 02243	387 N ESTRELLA PKWY	GOODYEAR	AZ	85338	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 02771	1305 S GREENFIELD RD	MESA	AZ	85206	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 02851	7000 N 16TH ST	PHOENIX	AZ	85020	04/15/2016	07/01/2016	07/01/2021	07/14/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03003	6690 W. UNION HILLS	GLENDALE	AZ	85308	04/15/2016	07/01/2016	07/01/2021	07/14/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03008	785 S. COOPER ROAD	GILBERT	AZ	85233	04/15/2016	07/01/2016	07/01/2021	07/14/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03048	9050 W UNION HILLS DRIVE	PEORIA	AZ	85382	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03049	4965 W BELL ROAD	GLENDALE	AZ	85308	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03132	2415 E. UNION HILLS DRIVE	PHOENIX	AZ	85050-3146	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03177	7011 E. SHEA BLVD.	SCOTTSDALE	AZ	85254	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03191	10865 NORTH TATUM BLVD.	PHOENIX	AZ	85028	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03387	10705 W INDIAN SCHOOL	AVONDALE	AZ	85392	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03464	3402 N CENTRAL AVE	PHOENIX	AZ	85012	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03477	204 E BELL RD	PHOENIX	AZ	85022	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03657	3361 NORTH LITCHFIELD RD	GOODYEAR	AZ	85395	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03727	1919 N DOBSON RD	CHANDLER	AZ	85224	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03767	2737 E. MCKELLIPS RD.	MESA	AZ	85213	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03768	6404 SOUTH MCCLINTOCK DR.	TEMPE	AZ	85283	04/15/2016	07/01/2016	07/01/2021	07/14/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03769	1616 E. THOMAS	PHOENIX	AZ	85016	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03789	3605 E THOMAS RD	PHOENIX	AZ	85018	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 04046	3960 E CHANDLER BLVD	PHOENIX	AZ	85048	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 04139	3450 W. DUNLAP AVE	PHOENIX	AZ	85051	04/15/2016	07/01/2016	07/01/2021	07/14/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 04422	3945 E SOUTHERN AVE	PHOENIX	AZ	85040	04/15/2016	07/01/2016	07/01/2021	07/14/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 04543	805 S. VAL VISTA DRIVE	GILBERT	AZ	85296	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 04620	15490 W BELL RD.	SURPRISE	AZ	85374	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 04762	2435 E GREENWAY PKWY	PHOENIX	AZ	85032	04/15/2016	07/01/2016	07/01/2021	07/14/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 04793	1975 S ALMA SCHOOL RD	CHANDLER	AZ	85286	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05215	2363 S LINDSAY RD	GILBERT	AZ	85295	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05453	6501 E GREENWAY PKWY BLDG 1	SCOTTSDALE	AZ	85254	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05504	4249 W GLENDALE AVE	PHOENIX	AZ	85051	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05505	3502 W CAMELBACK RD	PHOENIX	AZ	85019	04/15/2016	07/01/2016	09/30/2020	10/07/2020
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05776	1451 N DYSART ROAD	AVONDALE	AZ	85323	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05799	754 N HIGLEY RD	GILBERT	AZ	85234	04/15/2016	07/01/2016	07/01/2021	07/14/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05893	705 EAST MCDOWELL RD	PHOENIX	AZ	85006	04/15/2016	07/01/2016	07/01/2021	07/14/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05937	4315 W MCDOWELL RD	PHOENIX	AZ	85035	04/15/2016	07/01/2016	07/01/2021	07/14/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05938	4134 N 44TH ST	PHOENIX	AZ	85018	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06021	1620 N 59TH AVE	PHOENIX	AZ	85035	04/15/2016	07/01/2016	07/01/2021	07/14/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06535	2420 E BASELINE ROAD	PHOENIX	AZ	85042	04/15/2016	07/01/2016	07/01/2021	07/14/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06692	4766 E QUEEN CREEK RD	GILBERT	AZ	85297-8005	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06697	7606 S 7TH ST	PHOENIX	AZ	85042	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06872	2930 N 67TH AVE	PHOENIX	AZ	85033	04/15/2016	07/01/2016	07/01/2021	07/14/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07110	6640 W HAPPY VALLEY ROAD	GLENDALE	AZ	85310	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07375	1840 W SOUTHERN AVE	PHOENIX	AZ	85041-4631	04/15/2016	07/01/2016	02/20/2024	04/12/2024
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07387	10710 WEST MCDOWELL ROAD	AVONDALE	AZ	85392	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07516	2411 W ANTHEM WAY	ANTHEM	AZ	85086	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07558	9233 E GUADALUPE RD	MESA	AZ	85212	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07663	8280 W LOWER BUCKEYE ROAD	PHOENIX	AZ	85043	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07723	975 E OCOTILLO RD	CHANDLER	AZ	85249	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07933	15514 W WADDELL RD	SURPRISE	AZ	85379	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 09175	23477 W YUMA RD	BUCKEYE	AZ	85326	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 09179	5115 W BASELINE ROAD	LAVEEN	AZ	85339	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 09261	4710 E ROSE GARDEN LANE	PHOENIX	AZ	85050	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 09264	21274 N JOHN WAYNE PKWY	MARICOPA	AZ	85139	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA; WALGREENS #09460	40663 N. GANTZEL RD	SAN TAN VALLEY	AZ	85140-7008	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS #10260	3230 E CHANDLER HEIGHTS	GILBERT	AZ	85298	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS #12334	1654 N PEBBLE CREEK PKWY	GOODYEAR	AZ	85395	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS #12335	10825 E BASELINE RD	MESA	AZ	85209	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS #12386	9800 S. ESTRELLA PKWY.	GOODYEAR	AZ	85338	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03215	1935 NORTH POWER RD.	MESA	AZ	85205	04/15/2016	07/01/2016		07/26/2017
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 16082	10602 N. 32ND STREET	PHOENIX	AZ	85028	07/14/2021	10/01/2021		10/01/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	WALGREENS CENTRAL FILL #21372	120 N 83RD AVE STE 200	TOLLESON	AZ	85353	07/14/2021	10/01/2021		10/01/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS #12739	15450 N TATUM BLVD	PHOENIX	AZ	85032	07/14/2021	10/01/2021		10/01/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 11610	2000 S. MILL AVE.	TEMPE	AZ	85282	07/14/2021	10/01/2021		10/01/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	WALGREENS SPECIALTY PHARMACY #16431	2302 N. CENTRAL AVE. SUITE 7	PHOENIX	AZ	85004	07/14/2021	10/01/2021		10/01/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS #11470	25073 W SOUTHERN AVE	BUCKEYE	AZ	85326	07/14/2021	10/01/2021		10/01/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS #11181	5975 W. RAY RD	CHANDLER	AZ	85226-1827	07/14/2021	10/01/2021		10/01/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 13870	4875 E ELLIOT RD.	PHOENIX	AZ	85044	07/14/2021	10/01/2021		10/01/2021
Contract Detail	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03003	6690 W. UNION HILLS	GLENDALE	AZ	85308	04/12/2024	07/01/2024		07/01/2024
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	04/15/2016	07/01/2016	04/01/2024	04/12/2024
Contract Detail	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	04/16/2018	07/01/2018	07/01/2021	07/14/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	07/14/2021	10/01/2021		10/01/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/14/2021	10/01/2021		10/01/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	07/14/2021	10/01/2021		10/01/2021

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
PED033302-01	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s East Valley Surgery Center	5131 East Southern Avenue	Mesa	AZ	Active
PED033302-03	Child	PED	PHOENIX CHILDREN'S HOSPITAL	PHOENIX CHILDREN'S SPECIALTY CARE CENTER SCOTTSDALE - URGENT CARE	6990 E. Shea. Blvd.	SCOTTSDALE	AZ	Terminated
PED033302-06	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Dermatology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-07	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Endocrinology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-08	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Gastroenterology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-09	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Hematology and Oncology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-10	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Nephrology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-100	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Mercy Gilbert - Pulmonology	3420 Mercy Road	Gilbert	AZ	Active
PED033302-101	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Tucson - Dermatology	5983 E. Grant Road	Tucson	AZ	Terminated
PED033302-102	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Pediatrics	1501 N Gilbert Road	Gilbert	AZ	Terminated
PED033302-103	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Plastic Surgery	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-104	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Pediatrics	1501 N Gilbert Road	Gilbert	AZ	Terminated
PED033302-105	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Arrowhead - Neurology	18555 N 79th Avenue	Glendale	AZ	Terminated
PED033302-106	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Arrowhead - Developmental Pediatrics - Developmental Pediatrics	18555 N. 79th Avenue	Glendale	AZ	Terminated
PED033302-107	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Mercy Gilbert - Dermatology	3420 Mercy Road	Gilbert	AZ	Active
PED033302-108	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Mercy Gilbert - Genetics	3420 Mercy Road	Gilbert	AZ	Active
PED033302-109	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Mercy Gilbert - Pain Clinic	3420 Mercy Road	Gilbert	AZ	Active
PED033302-11	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Neurology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-110	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Pediatrics - Cottonwood	800 Cove Parkway	Cottonwood	AZ	Terminated
PED033302-111	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Pediatrics - San Tan Village	1790 E Boston Street	Gilbert	AZ	Terminated
PED033302-112	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Urology	6524 W SACK DR	Glendale	AZ	Active
PED033302-113	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Nephrology	6524 W SACK DR	Glendale	AZ	Active
PED033302-114	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Neurology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-115	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Allergy & Immunology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-116	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Tucson - Cardiology	5983 E Grant Road	Tucson	AZ	Terminated
PED033302-117	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Neuropsychology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-118	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center - Rheumatology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-119	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Endocrinology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-12	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Orthopedics	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-120	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center - Genetics	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-121	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center - Pain Medicine	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-122	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Northwest Valley Specialty Care Center - Neurosurgery	6524 W SACK DR	Glendale	AZ	Active
PED033302-123	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care at St. Joseph's - Plastic Surgery	124 W Thomas Road	Phoenix	AZ	Terminated
PED033302-124	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Cardiology - Casa Grande	1828 E Florence Boulevard, Building C	Casa Grande	AZ	Terminated
PED033302-125	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center - Radiology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-126	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center - Genetics	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-127	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Developmental Pediatrics	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-128	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center - Pediatric Surgery	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-129	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center - Pain Management	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-13	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Psychiatry	3370 Mercy Road	Gilbert	AZ	Active
PED033302-130	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care at St. Joseph's - Neurosurgery	124 W Thomas Road	Phoenix	AZ	Terminated
PED033302-131	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center - Plastic Surgery	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-132	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Pediatric Surgery	6524 W SACK DR	Glendale	AZ	Active
PED033302-133	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Cardiology - Douglas	815 15th Street	Douglas	AZ	Terminated
PED033302-134	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Plastic Surgery	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-135	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Developmental Pediatrics	6524 W SACK DR	Glendale	AZ	Active
PED033302-136	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Genetics	6524 W SACK DR	Glendale	AZ	Active
PED033302-137	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Arrowhead - Neurosurgery	18555 N 79th Avenue	Glendale	AZ	Terminated
PED033302-138	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Scottsdale Specialty Care Center - Plastic Surgery	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-139	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Tucson - Neurosurgery	5983 E Grant Road	Tucson	AZ	Terminated
PED033302-14	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - NeuroPsychology	3370 Mercy Road	Gilbert	AZ	Terminated
PED033302-140	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Scottsdale Specialty Care Center - Developmental Pediatrics	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-141	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Scottsdale Specialty Care Center - Pediatric Surgery	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-142	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Cardiology - Safford	2115 W 16th Street	Safford	AZ	Terminated
PED033302-143	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Plastic Surgery	3370 Mercy Road	Gilbert	AZ	Active
PED033302-144	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Cardiology - Sierra Vista	155 Calle Portal	Sierra Vista	AZ	Terminated
PED033302-145	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Psychology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-146	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Orthopedics	3370 S Mercy Road	Gilbert	AZ	Active
PED033302-147	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Ambulatory - Nephrology	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-148	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Neurosurgery	3370 Mercy Road	Gilbert	AZ	Active
PED033302-149	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Cardiology	3370 S Mercy Road	Gilbert	AZ	Active
PED033302-15	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Pulmonology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-150	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Pediatric Surgery	3370 Mercy Road	Gilbert	AZ	Active
PED033302-151	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Otolaryngology	3370 Mercy Road	Gilbert	AZ	Terminated
PED033302-152	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Gastroenterology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-153	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Ortho Radiology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-154	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Pediatric & Adolescent Gynecology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-155	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Developmental Pediatrics	3370 Mercy Road	Gilbert	AZ	Active
PED033302-156	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Mesa Pediatrics - Gilbert	2550 E Guadalupe Road	Gilbert	AZ	Terminated
PED033302-157	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Mesa Pediatrics - Chandler	60 S Kyrene Road	Chandler	AZ	Terminated
PED033302-158	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Mesa Pediatrics - Tempe	6301 S McClintock Drive	Tempe	AZ	Terminated
PED033302-159	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Mesa Pediatrics - San Tan	3592 S Atherton Blvd	Gilbert	AZ	Terminated
PED033302-16	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Radiology and Imaging	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-160	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Behavioral Health	3370 Mercy Road	Gilbert	AZ	Active
PED033302-161	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Scottsdale Specialty Care Center - Psychology	6990 E Shea Blvd	Scottssdale	AZ	Active
PED033302-162	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Southwest Valley Specialty Care Center - Allergy & Immunology	1665 N Avondale Blvd	Avondale	AZ	Active
PED033302-163	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital - Ambulatory Physical Medicine Clinic	1919 E. Thomas Rd	Phoenix	AZ	Active
PED033302-164	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Pulmonology - Pulmonology	3370 S Mercy Road	Gilbert	AZ	Active
PED033302-165	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Southwest Valley - Hand Surgery - Hand Surgery	1665 N Avondale Blvd	Avondale	AZ	Active
PED033302-166	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Southwest Valley - Developmental Pediatrics - Developmental Pediatrics	1665 N Avondale Blvd	Avondale	AZ	Active
PED033302-167	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Southwest Valley - Physical Medicine & Rehabilitation - Physical Medicine & Rehabilitation	1665 N Avondale Blvd	Avondale	AZ	Active
PED033302-168	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - GI Surgery - GI Surgery	5131 E Southern Ave	Mesa	AZ	Active
PED033302-169	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Scottsdale Specialty Care Center - GI Surgery - GI Surgery	6990 E Shea Blvd	Scottsdale	AZ	Active
PED033302-17	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s East Valley Specialty Care Center - Rheumatology	5131 E Southern Ave	Mesa	AZ	Active
PED033302-170	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Emergency Department - Avondale Campus - Emergency Department	1665 N Avondale Blvd	Avondale	AZ	Active
PED033302-18	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Urgent Care	5131 E Southern Ave	Mesa	AZ	Terminated
PED033302-19	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Endocrinology	6524 W SACK DR	Glendale	AZ	Active
PED033302-20	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Gastroenterology	6524 W SACK DR	Glendale	AZ	Active
PED033302-21	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Neurology	6524 W SACK DR	Glendale	AZ	Active
PED033302-22	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Orthopedics	6524 W SACK DR	Glendale	AZ	Active
PED033302-23	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Pulmonology	6524 W SACK DR	Glendale	AZ	Active
PED033302-24	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Urgent Care	20325 N 51st Avenue	Glendale	AZ	Terminated
PED033302-25	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Center - Scottsdale Cardiology	6990 E Shea Boulevard	Scottsdale	AZ	Terminated
PED033302-26	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Endocrinology	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-27	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Gastroenterology	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-28	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Scottsdale Specialty Care Center - Nephrology	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-29	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Neurology	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-30	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Orthopedics	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-31	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Pulmonology	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-32	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Urgent Care	6990 E Shea Boulevard	Scottsdale	AZ	Terminated
PED033302-33	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Urology	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-34	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Hospital Ambulatory - General Pediatrics	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-35	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic (Rosenberg Building) PCMG Gynecology	1920 E Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-36	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Clinic - Hematology/Oncology	1919 East Thomas Road	Phoenix	AZ	Terminated
PED033302-37	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Rosenberg Children's Medical Plaza - Nephrology	1920 E Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-38	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Rosenberg - Radiology & Imaging	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-39	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Rosenberg Children's Medical Plaza - Rheumatology	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-40	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Urology	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-41	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Hemodialysis	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-42	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Dermatology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-43	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Endocrinology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-44	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Gastroenterology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-45	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – General Pediatrics	1665 N Avondale Boulevard	Avondale	AZ	Terminated
PED033302-46	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Arrowhead Specialty Care Center – Hematology & Oncology Clinic	6524 W SACK DR	Glendale	AZ	Active
PED033302-47	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Neuropsychology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-48	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Neurology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-49	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Orthopedics	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-50	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Urgent Care	1665 N Avondale Boulevard	Avondale	AZ	Terminated
PED033302-51	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Psychiatry	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-52	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Pulmonology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-53	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Clinic - Neurology	1919 East Thomas Road	Phoenix	AZ	Terminated
PED033302-54	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Hospital Ambulatory - Audiology	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-55	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Hospital Ambulatory - Neurosurgery	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-56	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Hospital Ambulatory - Psychiatry	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-57	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Hospital Ambulatory - Psychology	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-58	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Hospital Ambulatory - Neurology	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-59	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Ambulatory Surgery Center	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-60	Child	PED	PHOENIX CHILDREN'S HOSPITAL	PCMG Radiology	1920 E. Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-61	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Urology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-62	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Rehabilitation	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-63	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Southwest Valley Specialty Care Center - Nephrology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-64	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg - Infusion Center	1920 E Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-65	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Peritoneal Dialysis	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-66	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Hemodialysis	1920 East Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-67	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Genetics and Metabolism	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-68	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Mercy Gilbert - Diagnostic Radiology	3555 South Val Vista Drive	Gilbert	AZ	Terminated
PED033302-69	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Mercy Gilbert - Respiratory Therapy	3555 South Val Vista Drive	Gilbert	AZ	Terminated
PED033302-70	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s East Valley Specialty Care Center - Neurosurgery	5131 East Southern Avenue	Mesa	AZ	Active
PED033302-71	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Neurosurgery	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-72	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Homeless Youth Outreach – UMOM New Day Center	3333 E Van Buren Street	Phoenix	AZ	Terminated
PED033302-73	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Cardiology - Scottsdale	10250 N 92nd Street	Scottsdale	AZ	Active
PED033302-74	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Homeless Youth Outreach - Crews'n Healthmobile	1919 E Thomas Road	Phoenix	AZ	Terminated
PED033302-75	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Homeless Youth Outreach – Children’s First Leadership Academy	1648 S 16th Street	Phoenix	AZ	Terminated
PED033302-76	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Breathmobile	1919 E Thomas Road	Phoenix	AZ	Terminated
PED033302-77	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Arrowhead - Cardiology	18555 N 79th Avenue	Glendale	AZ	Active
PED033302-78	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Heart Center - East Valley	3420 South Mercy Road	Gilbert	AZ	Terminated
PED033302-79	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Endocrinology	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-80	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Pediatrics - Scottsdale	5425 E Bell Road	Scottsdale	AZ	Terminated
PED033302-81	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s East Valley Specialty Care Center - Infusion Center	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-82	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Arrowhead Specialty Care Center - CCBD and Infusion Center	6524 W SACK DR	Glendale	AZ	Active
PED033302-83	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic (Rosenberg Building) PCMG Allergy & Immunology	1920 E Cambridge Ave	Phoenix	AZ	Terminated
PED033302-84	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Homeless Youth Outreach - Phoenix Dream Center	3210 NW Grand Avenue	Phoenix	AZ	Terminated
PED033302-85	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Gilbert - Cardiology	1501 N Gilbert Road	Gilbert	AZ	Terminated
PED033302-86	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Southwest Valley Specialty Care Center - Cardiology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-87	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Ophthalmology	3370 S Mercy Road	Glbert	AZ	Terminated
PED033302-88	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Ophthalmology – West Mesa	2045 S Vineyard Drive	Mesa	AZ	Terminated
PED033302-89	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Ophthalmology – Glendale	6320 W Union Hills Drive	Glendale	AZ	Terminated
PED033302-90	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Ophthalmology – Scottsdale	20201 N Scottsdale Healthcare Drive	Scottsdale	AZ	Terminated
PED033302-91	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Arizona Pediatric Eye Specialists - Shea	4530 East Shea Blvd.	Phoenix	AZ	Terminated
PED033302-92	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Rosenberg Children's Medical Plaza - Ophthalmology	1920 E Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-93	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Ophthalmology – West Phoenix	9250 W Thomas Rd	Phoenix	AZ	Terminated
PED033302-94	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Pediatrics – North Phoenix	3805 E Bell Road	Phoenix	AZ	Terminated
PED033302-95	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Pediatrics - Dobson Village	205 S Dobson Road	Chandler	AZ	Terminated
PED033302-96	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Speciality Care ENT/Otolaryngology - Mesa	2045 S Vineyard Drive	Mesa	AZ	Terminated
PED033302-97	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Rosenberg Children's Medical Plaza - ENT/Otolaryngology	1920 E Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-98	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care ENT/Otolarngology - West Phoenix	9250 W Thomas Road	Phoenix	AZ	Terminated
PED033302-99	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Urology	3370 S Mercy Road	Gilbert	AZ	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Delete	Change Request	SISU Healthcare Solutions, Inc. 914 S 52nd St Suite 110 Tempe, AZ 85281		3/19/2025 7:40 AM
Addresses	Shipping Address	Insert	Change Request		PHOENIX CHILDREN'S HOSPITAL - ARROWHEAD (Compounding Pharmacy) 19007 N 67TH AVE GLENDALE, AZ 85308	3/19/2025 7:40 AM
Details	Last Recertification Date	Update	Recertification	9/12/2023 7:45:21 AM	9/19/2024 7:00:24 AM	9/19/2024 7:00 AM
Details	Last Recertification Date	Update	Recertification	9/19/2022 11:24:58 AM	9/12/2023 7:45:21 AM	9/12/2023 7:45 AM
Contacts	Authorizing Official	Update	AO Change Request	Bruns, Dennis Executive Vice President & Chief Financial Officer Phoenix Children's Hospital 6029330221	Bruhn, Michelle Executive Vice President & Chief Financial Officer Phoenix Children's Hospital 6029330221	8/18/2023 12:50 PM
Details	Last Recertification Date	Update	Recertification	9/13/2021 10:08:25 AM	9/19/2022 11:24:58 AM	9/19/2022 11:24 AM
Contacts	Authorizing Official	Update	AO Change Request	Cornicelli, Kari Executive Vice President and Chief Financial Officer Phoenix Children's Hospital 6029335468	Bruns, Dennis Executive Vice President & Chief Financial Officer Phoenix Children's Hospital 6029330221	9/9/2022 7:00 AM
Contacts	Primary Contact	Update	Profile Change Request	Jaffery, Syed Director of Pharmacy (Business Operations) Phoenix Children's Hospital 6029335185	Jaffery, Syed Director of Pharmacy Business Operations Phoenix Children's Hospital 6029335185	8/24/2022 6:36 PM
Contacts	Primary Contact	Update	Profile Change Request	Jaffery, Syed Director of Pharmacy (Business Operations) Phoenix Children's Hospital 3174468568	Jaffery, Syed Director of Pharmacy (Business Operations) Phoenix Children's Hospital 6029335185	3/3/2022 3:49 PM
Contacts	Primary Contact	Update	Group Change Request	Dickman, Bethany Pharmacy Business Manager Phoenix Children's Hospital 6029334033	Jaffery, Syed Director of Pharmacy (Business Operations) Phoenix Children's Hospital 3174468568	12/30/2021 6:45 AM
Details	Last Recertification Date	Update	Recertification	9/1/2020 3:16:25 AM	9/13/2021 10:08:25 AM	9/13/2021 10:08 AM
Addresses	Shipping Address	Insert	Change Request		Safecor Health, LLC 4060 Business Park Dr. Columbus, OH 43204	5/20/2021 12:50 PM
Details	Last Recertification Date	Update	Recertification	9/9/2019 1:12:39 PM	9/1/2020 3:16:25 AM	9/1/2020 3:16 AM
Addresses	Shipping Address	Delete	Change Request	Coram Alternate Site Services, Inc. DBA Coram CVS/Specialty Infusion Services 4601 E. Hilton Avenue Suite 105 Phoenix, AZ 85034		7/7/2020 8:25 AM
Addresses	Shipping Address	Delete	Change Request	FUJII, DAVID (MD) PCSC MEDICAL DIRECTOR 1920 EAST CAMBRIDGE AVE, STE 100 Phoenix, AZ 85006		7/7/2020 8:25 AM
Addresses	Shipping Address	Insert	Change Request		SISU Healthcare Solutions, Inc. 914 S 52nd St Suite 110 Tempe, AZ 85281	4/14/2020 1:07 PM
Contacts	Primary Contact	Update	Change Request	Douthard, Yolanda Chief of Pharmacy Services Phoenix Children's Hospital 6029331891	Dickman, Bethany Pharmacy Business Manager Phoenix Children's Hospital 6029334033	1/31/2020 6:33 PM
Details	Last Recertification Date	Update	Recertification	9/6/2018 6:13:53 PM	9/9/2019 1:12:39 PM	9/9/2019 1:12 PM
Contacts	Authorizing Official	Update	AO Change Request	Higginson, David A COO Phoenix Childrens Hospital 4803995046	Cornicelli, Kari Executive Vice President and Chief Financial Officer Phoenix Children's Hospital 6029335468	9/5/2019 1:23 PM
Contacts	Primary Contact	Update	Change Request	Pharr, Matthew Manager, Pharmacy Business Services Phoenix Children's Hospital 6029334033	Douthard, Yolanda Chief of Pharmacy Services Phoenix Children's Hospital 6029331891	4/29/2019 8:07 AM
Contacts	Authorizing Official	Update	AO Change Request	Myers, Douglas T CFO Phoenix Childrens 6029331393	Higginson, David A COO Phoenix Childrens Hospital 4803995046	1/29/2019 10:46 AM
Addresses	Shipping Address	Insert	Change Request		Coram Alternate Site Services, Inc. DBA Coram CVS/Specialty Infusion Services 4601 E. Hilton Avenue Suite 105 Phoenix, AZ 85034	9/17/2018 2:33 PM
Addresses	Shipping Address	Delete	Change Request	Preferred Homecare Infusion 4601 E. Hilton Avenue Suite 105 Phoenix, AZ 85034		9/17/2018 2:33 PM
Details	Last Recertification Date	Update	Recertification	11/8/2017 2:14:53 PM	9/6/2018 6:13:53 PM	9/6/2018 6:13 PM
Contacts	Primary Contact	Update	Change Request	Douthard, Yolanda CHIEF OF PHARMACY Phoenix Children's Hospital 6029331891	Pharr, Matthew Manager, Pharmacy Business Services Phoenix Children's Hospital 6029334033	1/24/2018 11:43 AM
Contacts	Authorizing Official	Update	AO Change Request	MCKNIGHT, CRAIG CFO Phoenix Childrens Hospital 6025465468	Myers, Douglas T CFO Phoenix Childrens 6029331393	12/13/2017 1:19 PM
Details	Last Recertification Date	Update	Recertification	8/17/2016 12:00:00 AM	11/8/2017 2:14:53 PM	11/8/2017 2:14 PM
Contacts	Authorizing Official	Update		MCKNIGHT, CRAIG CFO 6025465468	MCKNIGHT, CRAIG CFO Phoenix Childrens Hospital 6025465468	11/7/2017 5:11 PM
Contacts	Primary Contact	Update		Douthard, Yolanda CHIEF OF PHARMACY 6029331891	Douthard, Yolanda CHIEF OF PHARMACY Phoenix Children's Hospital 6029331891	10/15/2017 7:00 PM
Contacts	Authorizing Official	Insert			MCKNIGHT, CRAIG CFO 6025465468	8/14/2017 1:35 PM
Contacts	Primary Contact	Update		Thomas, Donnie Pharmacy 340B Coordinator 6029331878	Douthard, Yolanda CHIEF OF PHARMACY 6029331891	8/14/2017 1:35 PM
Addresses	Main Address	Insert			1919 E THOMAS ROAD PHOENIX, AZ 85016	7/26/2017 11:47 AM
Addresses	Shipping Address	Insert			Preferred Homecare Infusion 4601 E. Hilton Avenue Suite 105 Phoenix, AZ 85034	7/26/2017 11:47 AM
Addresses	Shipping Address	Insert			FUJII, DAVID (MD) PCSC MEDICAL DIRECTOR 1920 EAST CAMBRIDGE AVE, STE 100 Phoenix, AZ 85006	7/26/2017 11:47 AM
Details	Last Recertification Date	Update		8/27/2015 12:00:00 AM	8/17/2016 12:00:00 AM	8/17/2016 6:26 PM
Details	Last Recertification Date	Update		8/21/2014 12:00:00 AM	8/27/2015 12:00:00 AM	8/27/2015 11:19 AM
Details	Last Recertification Date	Update		8/19/2013 12:00:00 AM	8/21/2014 12:00:00 AM	8/21/2014 2:03 PM
Contacts	Primary Contact	Insert			Thomas, Donnie Pharmacy 340B Coordinator 6029331878	8/19/2013 9:17 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/19/2013 12:00:00 AM	8/19/2013 9:17 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/8/2012 7:20 AM
Details	Comments Public	Insert			4/12/12 ADDED SHIP ADD 2; 1/10/12 ADDED SHIP-TO ADD	4/12/2012 2:43 PM
Details	Comments Public	Insert			1/10/12 ADDED SHIP-TO ADD	1/10/2012 1:22 PM
Details	Last Recertification Date	Insert				3/26/2010 10:56 AM
Details	Grant Number	Insert				3/26/2010 10:56 AM
Details	340B ID	Insert			PED033302-00	3/26/2010 10:56 AM
Details	Is Authorizing Official EHB Data	Insert				3/26/2010 10:56 AM
Dates	Last Date That 340B Drugs Purchased	Insert				3/26/2010 10:56 AM
Details	Medicare Provider Number	Insert			033302	3/26/2010 10:56 AM
Details	Entity Name	Insert			PHOENIX CHILDREN'S HOSPITAL	3/26/2010 10:56 AM
Details	Program Code	Insert			PED	3/26/2010 10:56 AM
Details	Entity Subname	Insert				3/26/2010 10:56 AM
Dates	Participating Approval Date	Insert			3/26/2010 12:00:00 AM	3/26/2010 10:56 AM
Details	State	Insert			Active	3/26/2010 10:56 AM
Dates	Registration Date	Insert			3/25/2010 12:00:00 AM	3/26/2010 10:56 AM
Dates	Signed By Date	Insert			3/25/2010 12:00:00 AM	3/26/2010 10:56 AM
Dates	Start Date	Insert			4/1/2010 12:00:00 AM	3/26/2010 10:56 AM
Terminations	Termination Comments	Insert				3/26/2010 10:56 AM
Terminations	Termination Date	Insert				3/26/2010 10:56 AM
Terminations	Termination Effective Date	Insert				3/26/2010 10:56 AM
Terminations	Termination Reason	Insert				3/26/2010 10:56 AM