Covered Entity Details

DSH030111L Banner - University Medical Center South (Terminated) - information as of 5/20/2025 11:39:16 PM

Main Details

Name

Banner - University Medical Center South

Subdivision Name

Alvernon Ophthamology and Optometry

Type

Disproportionate Share Hospital

Rural

340B ID

DSH030111L

Medicare Provider Number

030111

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

11/15/2011

Participating Start Date

1/1/2012

Participating Approval Date

12/27/2011

Last Recertification Date

8/26/2015

Termination Date
Termination Reason

4/1/2016
Site closure

Contacts

Authorizing Official

Banner University Medical Centers Tucson and South
Brad Hipp, Chief Financial Officer
(520) 694-3446

Primary Contact

Albert Cortese, Director of Pharmacy Services
(520) 874-2510

Addresses

Street Address

707 N. Alvernon, Suite 301
Tucson, AZ 85711

Billing Address

Banner University Medical Center South
2800 E. Ajo Way
attn: Pharmacy
Tucson, AZ 85713

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	874223
		1811048895,1104887199,1770742959,1558759498,1801284617

Shipping Addresses

Shipping Address 1

Banner University Medical Center South
2800 E Ajo Way
attn: Pharmacy
Tucson, AZ 85713

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	Authorizing Official	Update	Change Request	Frost, Sarah Chief Operating Officer Banner UMC South and Tucson campuses 5206943445	Hipp, Brad Chief Financial Officer Banner University Medical Centers Tucson and South 5206943446	7/26/2019 10:20 AM
Contacts	Authorizing Official	Update	Change Request	Polashek, Maurene Sr Dir Finance Banner University Medical Centers Tucson/South 5206943446	Frost, Sarah Chief Operating Officer Banner UMC South and Tucson campuses 5206943445	9/20/2018 7:24 AM
Contacts	Authorizing Official	Update	Change Request	Polashek, Maurene Sr Dir Finance 5206943446	Polashek, Maurene Sr Dir Finance Banner University Medical Centers Tucson/South 5206943446	10/10/2017 3:53 PM
Contacts	Authorizing Official	Update		Loader, Cliff Chief Financial Officer 6028392675	Polashek, Maurene Sr Dir Finance 5206943446	9/11/2017 3:29 PM
Contacts	Authorizing Official	Update		BOTSFORD, NORM CEO AND PRESIDENT 5208744289	Loader, Cliff Chief Financial Officer 6028392675	8/4/2017 1:31 PM
Contacts	Signed By	Insert			Frost, Sarah Site Administrator 5208743521	6/23/2017 11:11 AM
Contacts	Primary Contact	Update		Hinman, Clint Director of Pharmacy Services 5208742510	Cortese, Albert Director of Pharmacy Services 5208742510	6/23/2017 11:11 AM
Addresses	Main Address	Insert			707 N. Alvernon, Suite 301 Tucson, AZ 85711	4/8/2016 10:25 AM
Addresses	Billing Address	Insert			Banner University Medical Center South 2800 E. Ajo Way attn: Pharmacy Tucson, AZ 85713	4/8/2016 10:25 AM
Addresses	Shipping Address	Insert			Banner University Medical Center South 2800 E Ajo Way attn: Pharmacy Tucson, AZ 85713	4/8/2016 10:25 AM
Details	Entity Name	Update		Banner – University Medical Center South	Banner - University Medical Center South	4/8/2016 10:25 AM
Dates	Last Date That 340B Drugs Purchased	Update			12/29/2015 12:00:00 AM	1/15/2016 2:41 PM
Details	State	Update		Active	Terminated	1/15/2016 2:41 PM
Terminations	Termination Comments	Update			This site will operate as a free-standing clinic. As of 1/1/16, it will not be a reimburseable area on the Medicare Cost Report for the parent site. This termination request applies only to the Ophthalmology and Optometry Clinic (DSH030111L); there are no changes to the parent site (DSH030111) or the other child sites at this time.	1/15/2016 2:41 PM
Terminations	Termination Date	Update			4/1/2016 12:00:00 AM	1/15/2016 2:41 PM
Terminations	Termination Effective Date	Update			1/1/2016 12:00:00 AM	1/15/2016 2:41 PM
Terminations	Termination Reason	Update			Site closure	1/15/2016 2:41 PM
Details	Last Recertification Date	Update		8/20/2014 12:00:00 AM	8/26/2015 12:00:00 AM	8/26/2015 1:48 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/14/2015 1:18 PM
Medicaid Billing	Medicaid: Number	Insert			874223	7/14/2015 1:18 PM
Medicaid Billing	Medicaid: State	Insert			AZ	7/14/2015 1:18 PM
Medicaid Billing	NPI: Number	Insert			1104887199	7/14/2015 1:18 PM
Medicaid Billing	NPI: Number	Insert			1770742959	7/14/2015 1:18 PM
Medicaid Billing	NPI: Number	Insert			1558759498	7/14/2015 1:18 PM
Medicaid Billing	NPI: Number	Insert			1801284617	7/14/2015 1:18 PM
Details	Entity Name	Update		UNIVERSITY PHYSICIANS HEALTHCARE HOSPITAL AT KINO CAMPUS (UPHK)	Banner – University Medical Center South	4/24/2015 12:35 PM
Details	Last Recertification Date	Update		9/11/2013 8:16:05 PM	8/20/2014 12:00:00 AM	8/20/2014 12:01 PM
Contacts	Primary Contact	Insert			Hinman, Clint Director of Pharmacy Services 5208742510	8/18/2014 6:20 AM
Details	Last Recertification Date	Update			9/11/2013 8:16:05 PM	9/11/2013 8:16 PM
Dates	Participating Approval Date	Update			12/27/2011 12:00:00 AM	12/27/2011 5:20 PM
Details	State	Update		Pending	Active	12/27/2011 5:20 PM
Details	340B ID	Update		JH111711N	DSH030111L	12/9/2011 11:29 AM
Dates	Start Date	Update			1/1/2012 12:00:00 AM	12/9/2011 11:29 AM
Contacts	Authorizing Official	Insert			BOTSFORD, NORM CEO AND PRESIDENT 5208744289	11/18/2011 1:52 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	JH111711N	11/18/2011 1:49 PM
Medicaid Billing	NPI: Number	Insert			1811048895	11/15/2011 11:34 AM
Details	Last Recertification Date	Insert				11/15/2011 11:34 AM
Details	Grant Number	Insert				11/15/2011 11:34 AM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	11/15/2011 11:34 AM
Details	Is Authorizing Official EHB Data	Insert				11/15/2011 11:34 AM
Dates	Last Date That 340B Drugs Purchased	Insert				11/15/2011 11:34 AM
Details	Medicare Provider Number	Insert			030111	11/15/2011 11:34 AM
Details	Entity Name	Insert			UNIVERSITY PHYSICIANS HEALTHCARE HOSPITAL AT KINO CAMPUS (UPHK)	11/15/2011 11:34 AM
Details	Program Code	Insert			DSH	11/15/2011 11:34 AM
Details	Entity Subname	Insert			Alvernon Ophthamology and Optometry	11/15/2011 11:34 AM
Dates	Participating Approval Date	Insert				11/15/2011 11:34 AM
Details	State	Insert			Pending	11/15/2011 11:34 AM
Dates	Registration Date	Insert			11/15/2011 12:00:00 AM	11/15/2011 11:34 AM
Dates	Signed By Date	Insert			11/15/2011 12:00:00 AM	11/15/2011 11:34 AM
Dates	Start Date	Insert				11/15/2011 11:34 AM
Terminations	Termination Comments	Insert				11/15/2011 11:34 AM
Terminations	Termination Date	Insert				11/15/2011 11:34 AM
Terminations	Termination Effective Date	Insert				11/15/2011 11:34 AM
Terminations	Termination Reason	Insert				11/15/2011 11:34 AM