| Details | Last Recertification Date | Update | Recertification | 8/16/2023 1:32:52 PM | 8/16/2024 4:38:38 PM | 8/16/2024 4:38 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Schultz, Mitchell
RPh, 340b Division Manager
CommonSpirit Health - Midwest Division
7019280620 | Schultz, Mitchell
RPh, 340b Regional Manager
CommonSpirit Health - Central Region
7019280620 | 8/6/2024 1:57 PM |
| Contacts | Primary Contact | Update | Group Change Request | Pearcy, Ryan
340B Division Manager
CommonSpirit Health
8592295654 | Schultz, Mitchell
RPh, 340b Division Manager
CommonSpirit Health - Midwest Division
7019280620 | 7/10/2024 3:31 PM |
| Details | Last Recertification Date | Update | Recertification | 9/7/2022 4:08:55 PM | 8/16/2023 1:32:52 PM | 8/16/2023 1:32 PM |
| Details | Last Recertification Date | Update | Recertification | 8/23/2021 9:43:50 AM | 9/7/2022 4:08:55 PM | 9/7/2022 4:08 PM |
| Contacts | Primary Contact | Update | Change Request | Mesdaghi, Mike
Senior Director of Pharmacy
Dignity Health
6024064744 | Pearcy, Ryan
340B Division Manager
CommonSpirit Health
8592295654 | 1/31/2022 10:29 AM |
| Details | Last Recertification Date | Update | Recertification | 8/28/2020 9:31:58 AM | 8/23/2021 9:43:50 AM | 8/23/2021 9:43 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Jackson, Jeffrey
VP Finance
St.Joseph's Hospital and Medical Center
6024064618 | Jackson, Jeffrey
Chief Financial Officer
St.Joseph's Hospital and Medical Center
6024064618 | 3/23/2021 8:08 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Mesdaghi, Pooyan
Senior Director of Pharmacy
Dignity Health
6024064744 | Mesdaghi, Mike
Senior Director of Pharmacy
Dignity Health
6024064744 | 3/22/2021 7:10 AM |
| Addresses | Shipping Address | Delete | Change Request | UA Cancer Center/Dignity Health St. Joseph’s
625 N. 6th Street
Phoenix, AZ 85004 | | 2/8/2021 12:20 PM |
| Addresses | Shipping Address | Insert | Change Request | | Dignity Health Cancer Institute at St Joseph
625 N. 6th Street
Phoenix, AZ 85004 | 2/8/2021 12:20 PM |
| Details | Entity Subname | Update | Change Request | UA Cancer Center/Dignity Health St. Joseph’s | Dignity Health Cancer Institute at St Joseph | 2/8/2021 12:20 PM |
| Contacts | Primary Contact | Update | Change Request | Blank, Greg
Director of Pharmacy
St. Joseph's Hospital and Medical Center
6024064744 | Mesdaghi, Pooyan
Senior Director of Pharmacy
Dignity Health
6024064744 | 9/9/2020 12:07 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | AZ | 8/28/2020 9:31 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | AZ | 8/28/2020 9:31 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | AZ | 8/28/2020 9:31 AM |
| Details | Last Recertification Date | Update | Recertification | 8/22/2019 6:11:37 PM | 8/28/2020 9:31:58 AM | 8/28/2020 9:31 AM |
| Details | Last Recertification Date | Update | Recertification | 8/31/2018 11:19:01 AM | 8/22/2019 6:11:37 PM | 8/22/2019 6:11 PM |
| Contacts | Primary Contact | Update | Change Request | Leach, Mark
Pharmacy Director
Dignity Health
6024060353 | Blank, Greg
Director of Pharmacy
St. Joseph's Hospital and Medical Center
6024064744 | 4/1/2019 6:43 AM |
| Addresses | Shipping Address | Insert | Change Request | | St.Joseph's Hospital and Medical Center
350 W. Thomas Rd
Phoenix, AZ 85013 | 12/10/2018 8:17 AM |
| Addresses | Shipping Address | Insert | Change Request | | UA Cancer Center/Dignity Health St. Joseph’s
625 N. 6th Street
Phoenix, AZ 85004 | 12/10/2018 8:17 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1952775298 | 10/11/2018 5:45 PM |
| Details | Last Recertification Date | Update | Recertification | 11/6/2017 11:26:33 AM | 8/31/2018 11:19:01 AM | 8/31/2018 11:19 AM |
| Addresses | Billing Address | Insert | Change Request | | Dignity Health Accounts Payable
3033 N. 3rd Avenue
Phoenix, AZ 85013 | 6/15/2018 11:42 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1326084872 | 6/15/2018 11:42 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 12/12/2017 8:50 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 691974 | 12/12/2017 8:50 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | AZ | 12/12/2017 8:50 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1982733655 | 12/12/2017 8:50 AM |
| Details | Last Recertification Date | Update | Recertification | 8/17/2016 12:00:00 AM | 11/6/2017 11:26:33 AM | 11/6/2017 11:26 AM |
| Contacts | Authorizing Official | Update | | Jackson, Jeffrey
VP Finance
6024064618 | Jackson, Jeffrey
VP Finance
St.Joseph's Hospital and Medical Center
6024064618 | 10/20/2017 11:25 AM |
| Contacts | Primary Contact | Update | | Leach, Mark
Pharmacy Director
6024060353 | Leach, Mark
Pharmacy Director
Dignity Health
6024060353 | 9/25/2017 7:46 PM |
| Contacts | Authorizing Official | Insert | | | Jackson, Jeffrey
VP Finance
6024064618 | 7/17/2017 12:08 PM |
| Addresses | Main Address | Insert | | |
625 N. 6th Street
PHOENIX, AZ 85004 | 8/17/2016 7:18 AM |
| Contacts | Signed By | Insert | | | Jackson, Jeff
VP of Finance
6024064618 | 8/17/2016 7:18 AM |
| Contacts | Primary Contact | Update | | Hynes, Phillip
Director - Laboratory Services
6024066212 | Leach, Mark
Pharmacy Director
6024060353 | 8/17/2016 7:18 AM |
| Details | Last Recertification Date | Update | | 8/26/2015 12:00:00 AM | 8/17/2016 12:00:00 AM | 8/17/2016 7:18 AM |
| Details | Entity Subname | Update | | UACC Infusion Center | UA Cancer Center/Dignity Health St. Joseph’s | 9/10/2015 2:22 PM |
| Details | Last Recertification Date | Update | | 9/8/2014 12:00:00 AM | 8/26/2015 12:00:00 AM | 8/26/2015 12:15 PM |
| Contacts | Primary Contact | Insert | | | Hynes, Phillip
Director - Laboratory Services
6024066212 | 9/8/2014 1:30 PM |
| Details | Last Recertification Date | Update | | | 9/8/2014 12:00:00 AM | 9/8/2014 1:30 PM |
| Dates | Participating Approval Date | Update | | | 6/13/2014 12:00:00 AM | 6/13/2014 6:52 PM |
| Details | State | Update | | Pending | Active | 6/13/2014 6:52 PM |
| Dates | Start Date | Update | | | 7/1/2014 12:00:00 AM | 6/13/2014 6:52 PM |
| Details | 340B ID | Update | | Trial Balance? | DSH030024D | 4/10/2014 2:50 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG | Trial Balance? | 4/8/2014 3:43 PM |
| Details | Last Recertification Date | Insert | | | | 4/7/2014 5:42 PM |
| Details | Grant Number | Insert | | | | 4/7/2014 5:42 PM |
| Details | 340B ID | Insert | | | OUTPATIENT_ONLINE_REG | 4/7/2014 5:42 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 4/7/2014 5:42 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/7/2014 5:42 PM |
| Details | Medicare Provider Number | Insert | | | 030024 | 4/7/2014 5:42 PM |
| Details | Entity Name | Insert | | | ST JOSEPH'S HOSPITAL AND MEDICAL CENTER | 4/7/2014 5:42 PM |
| Details | Program Code | Insert | | | DSH | 4/7/2014 5:42 PM |
| Details | Entity Subname | Insert | | | UACC Infusion Center | 4/7/2014 5:42 PM |
| Dates | Participating Approval Date | Insert | | | | 4/7/2014 5:42 PM |
| Details | State | Insert | | | Pending | 4/7/2014 5:42 PM |
| Dates | Registration Date | Insert | | | 4/7/2014 12:00:00 AM | 4/7/2014 5:42 PM |
| Dates | Signed By Date | Insert | | | 4/7/2014 12:00:00 AM | 4/7/2014 5:42 PM |
| Dates | Start Date | Insert | | | | 4/7/2014 5:42 PM |
| Terminations | Termination Comments | Insert | | | | 4/7/2014 5:42 PM |
| Terminations | Termination Date | Insert | | | | 4/7/2014 5:42 PM |
| Terminations | Termination Effective Date | Insert | | | | 4/7/2014 5:42 PM |
| Terminations | Termination Reason | Insert | | | | 4/7/2014 5:42 PM |