340B Drug Pricing Program Database


CH09289P NORTH COUNTRY HEALTHCARE, INC. (Active) - information as of 6/22/2025 12:12:51 AM

Main Details
NORTH COUNTRY HEALTHCARE, INC.
NORTH COUNTRY HEALTHCARE- PAYSON
HRSA-Funded Health Center
BPS-H80-021234
CH09289P
H80CS00651


Additional Details
Active
7/8/2014
10/1/2014
7/23/2014
2/25/2025

Contacts

North Country HealthCare
ANNE NEWLAND, CEO
(928) 522-9564

North Country HealthCare
Andrew Kurtz, Director of Pharmacy
(928) 522-1073

Addresses

126 E Main St, Ste B
PAYSON, AZ 85541

NORTH COUNTRY HEALTHCARE
PO BOX 3630
FLAGSTAFF, AZ 86003


  • Comments
  • Medicaid Billing
  • Shipping Addresses
  • Contract Pharmacies
  • Grantee Sites
  • Grantee Sites Contract Pharmacies
  • History
Comments
CommentLast Updated On 
No records to display.
Medicaid Billing

Yes
StateMedicaid NumberNPI Number
AZ497094,433079,907998,9682151093146755,1073583472,1649334442,1053587261
Shipping Addresses

North Country HealthCare
2920 N 4th Street
Flagstaff, AZ 86004

North Country HealthCare
1 Clinic Road
Grand Canyon, AZ 86023

North Country HealthCare
1510 Stockton Hill Road
Kingman, AZ 86401

North Country HealthCare - Payson
126 E Main Street
Suite B
Payson, AZ 85541
Grantee Sites
340B ID 340B StatusSiteIdNameSub NameAddressAddress Cont.CityState
CH092890ActiveBPS-H80-003833NORTH COUNTRY HEALTHCARE, INC.NORTH COUNTRY - FLAGSTAFF CLINIC2920 N 4th St FlagstaffAZ
CH09289BTerminatedBPS-H80-006769NORTH COUNTRY HEALTHCARE, INC.NORTH COUNTRY - ASH FORK SITE112 PARK AVENUE ASH FORKAZ
CH09289CActiveBPS-H80-005416NORTH COUNTRY HEALTHCARE, INC.NORTHY COUNTRY - GRAND CANYON SITE1 CLINIC ROAD GRAND CANYONAZ
CH09289DActiveBPS-H80-010532NORTH COUNTRY HEALTHCARE, INC.NORTH COUNTRY - HOLBROOK CLINIC2109 Navajo Blvd HolbrookAZ
CH09289EActiveBPS-H80-008372NORTH COUNTRY HEALTHCARE, INC.NORTH COUNTRY - SHOW LOW CLINIC2650 E Show Low Lake Rd Show LowAZ
CH09289FTerminatedBPS-H80-004303NORTH COUNTRY HEALTHCARE, INC.NORTH COUNTRY - ST JOHNS CLINIC625 N. 13TH WEST STREET ST. JOHNSAZ
CH09289GActiveBPS-H80-003331NORTH COUNTRY HEALTHCARE, INC.NORTH COUNTRY - WINSLOW SITE620 WEST LEE STREET WinslowAZ
CH09289HActiveBPS-H80-008180NORTH COUNTRY HEALTHCARE, INC.NORTH COUNTRY - LAKE HAVASU CITY CLINIC2090 NORTH SMOKETREE AVE LAKE HAVASUAZ
CH09289ITerminatedBPS-H80-006323NORTH COUNTRY HEALTHCARE, INC.NORTH COUNTRY CHC-SELIGMAN SITE22585 W. OAK STREET SELIGMANAZ
CH09289JActiveBPS-H80-010837NORTH COUNTRY HEALTHCARE, INC.NORTH COUNTRY - SPRINGERVILLE CLINIC488 S MOUNTAIN AVE SPRINGERVILLEAZ
CH09289KActiveBPS-H80-009474NORTH COUNTRY HEALTHCARE, INC.Kingman Clinic1510 Stockton Hill Road KingmanAZ
CH09289LActiveBPS-H80-010471NORTH COUNTRY HEALTHCARE, INC.NORTH COUNTRY - BULLHEAD CITY2585 MIRACLE MILE STE 116 BULLHEAD CITYAZ
CH09289MActiveBPS-H80-030791NORTH COUNTRY HEALTHCARE, INC.NORTH COUNTRY HEALTHCARE- WILLIAMS300 S 6th St WilliamsAZ
CH09289NTerminatedBPS-H80-008454NORTH COUNTRY HEALTHCARE, INC.NORTH COUNTRY - FLAGSTAFF CO-LOCATION SITE2187 NORTH VICKEY STREET STE 2 FLAGSTAFFAZ
CH09289PActiveBPS-H80-021234NORTH COUNTRY HEALTHCARE, INC.NORTH COUNTRY HEALTHCARE- PAYSON126 E Main St, Ste B PAYSONAZ
CH09289QActiveBPS-H80-013657NORTH COUNTRY HEALTHCARE, INC.North Country HealthCare Mobile Unit1501 S Yale Ste 252 FlagstaffAZ
CH09289RActiveBPS-H80-017139NORTH COUNTRY HEALTHCARE, INC.NORTH COUNTRY - UNINCORPORATED FLAGSTAFF1120 W University Ave Ste 101 FlagstaffAZ
CH09289SActiveBPS-H80-019440NORTH COUNTRY HEALTHCARE, INC.North Country - Kingman Integration3505 WESTERN AVE Ste B KINGMANAZ
CH09289TActiveBPS-H80-019501NORTH COUNTRY HEALTHCARE, INC.North Country HealthCare- Flagstaff Pediatrics1501 S Yale St Ste 252 FlagstaffAZ
CH09289UActiveBPS-H80-032073North Country Healthcare, Inc.NORTH COUNTRY - MOBILE UNIT WEST1510 N Stockton Hill Rd KingmanAZ
Grantee Sites Contract Pharmacies
340B IDPharmacy NameAddressAddress Cont.CityStateZip CodeBegin DateCarve-In Effective DateTermination Date
CH092890ACCREDO HEALTH GROUP INC2040 W RIO SALADO PKWY STE 101B
TEMPEAZ85281-201010/01/2023  
CH092890ACCREDO HEALTH GROUP INC1620 CENTURY CENTER PKWY # 109
MEMPHISTN38134-884910/01/2023  
CH092890ACCREDO HEALTH GROUP INC3000 ERICSSON DRIVE, SUITE 100
WARRENDALEPA15086-750210/01/2023  
CH092890ACCREDO HEALTH GROUP, INC.2 BOULDEN CIR STE 1
NEW CASTLEDE19720-349210/01/2023  
CH092890ACCREDO HEALTH GROUP, INC.4750 E 450 S SUITE A
WHITESTOWNIN4607510/01/2023  
CH092890ACCREDO HEALTH GROUP, INC.6272 LEE VISTA BLVD STE 100
ORLANDOFL3282210/01/2023  
CH092890ALBERTSON'S LLCALBERTSON'S PHARMACY #3204 1980 MCCULLOCH BLVD
LAKE HAVASU CITYAZ8640301/01/2020  
CH092890ARIZONA CVS STORES, L.L.C.DBA: CVS/PHARMACY # 07022 75 N. LAKE HAVASU AVE.
LAKE HAVASU CITYAZ8640310/01/2017  
CH092890ARIZONA CVS STORES, L.L.C.DBA: CVS/PHARMACY # 09231 3506 EAST ROUTE 66
FLAGSTAFFAZ8600410/01/2017  
CH092890ARIZONA CVS STORES, L.L.C.DBA: CVS/PHARMACY # 08826 2350 MIRACLE MILE
BULLHEAD CITYAZ8644210/01/2019  
CH092890ARIZONA CVS STORES, L.L.C.DBA: CVS/PHARMACY # 08977 3501 STOCKTON HILL RD.
KINGMANAZ8640910/01/2019  
CH09289LARIZONA CVS STORES, L.L.C.DBA: CVS/PHARMACY # 08826 2350 MIRACLE MILE
BULLHEAD CITYAZ8644207/01/2024  
CH09289HARIZONA CVS STORES, L.L.C.DBA: CVS/PHARMACY # 07022 75 N. LAKE HAVASU AVE.
LAKE HAVASU CITYAZ8640307/01/2024  
CH09289SARIZONA CVS STORES, L.L.C.DBA: CVS/PHARMACY # 08977 3501 STOCKTON HILL RD.
KINGMANAZ8640907/01/2024  
CH092890BIOPLUS SPECIALTY PHARMACY SERVICES, LLCBIOPLUS SPECIALTY PHARMACY SERVICES, LLC 4740 VICTORY LN STE C
INDIANAPOLISIN4620301/01/2025  
CH092890BIOPLUS SPECIALTY PHARMACY SERVICES, LLC4900 PROSPECTUS DR STE 300
DURHAMNC2771301/01/2025  
CH092890BIOPLUS SPECIALTY PHARMACY SERVICES, LLC376 NORTHLAKE BLVD
ALTAMONTE SPRINGSFL32701-526101/01/2025  
CH092890BIOPLUS SPECIALTY PHARMACY SERVICES, LLC13925 YALE AVE STE 145
IRVINECA92620-267001/01/2025  
CH092890BIOPLUS SPECIALTY PHARMACY SERVICES, LLCBIOPLUS SPECIALTY PHARMACY SERVICES, LLC 145 S 79TH ST STE 70
CHANDLERAZ8522601/01/2025  
CH092890CAREMARK FLORIDA SPECIALTY PHARMACY LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 7930 WOODLAND CENTER BLVD STE 500
TAMPAFL3361410/01/2021  
CH092890CAREMARK ILLINOIS SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 800 BIERMANN CT STE B
MOUNT PROSPECTIL6005610/01/2021  
CH092890CAREMARK KANSAS SPECIALTY PHARMACYCVS/SPECIALTY OR CARELONRX SPECIALTY PHA 11162 RENNER BLVD
LENEXAKS6621910/01/2021  
CH092890CAREMARK MASSACHUSETTS SPECIALTY PHARMACDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 25 BIRCH STREET, BLDG B, SUITE 100
MILFORDMA0175710/01/2021  
CH092890CAREMARK MICHIGAN SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1307 ALLEN DR STE H
TROYMI4808310/01/2021  
CH092890CAREMARK NEW JERSEY SPECIALTY PHCY, LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 180 PASSAIC AVE UNIT B-5
FAIRFIELDNJ0700410/01/2021  
CH092890CAREMARK NORTH CAROLINA SPECIALTY PHARMADBA CVS/SPECIALTY OR CARELONRX SPECIALTY 10700 WORLD TRADE BLVD STE 110
RALEIGHNC2761710/01/2021  
CH092890CAREMARK TENNESSEE SPECIALTY PHARMACY, LDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 8370 WOLF LAKE DR
STE 107
BARTLETTTN3813310/01/2021  
CH092890CAREMARK, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1127 BRYN MAWR AVE
SUITE A
REDLANDSCA9237410/01/2021  
CH092890CAREMARK, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 7251 S. EASTERN AVE.
LAS VEGASNV8911910/01/2021  
CH092890CVS CAREMARKDBA CVS/CAREMARK OR CF# 11506 1 GREAT VALLEY BOULEVARD
WILKES BARREPA1870601/01/2023  
CH092890CVS CAREMARK ADVANCED TECHNOLOGY PHARMACDBA CVS/CAREMARK 48067 1780 WALL ST
MT PROSPECTIL6005601/01/2023  
CH092890CVS/SPECIALTY OR CARELONRX SPECIALTY PHACAREMARK, LLC 1001 SPINKS ROAD, STE 280
FLOWER MOUNDTX7502810/01/2021  
CH092890DOGWOOD PHARMACY LLCD/B/A MEDSCRIPTS MEDICAL PHARMACY 1325 MILLER RD
STE K
GREENVILLESC29607-654101/01/2025  
CH092890ESI MAIL PHARMACY SERVICEDBA EXPRESS SCRIPTS 7909 S HARDY DR STE 106
TEMPEAZ85284-111210/01/2023  
CH092890EXPRESS SCRIPTSESI MAIL PHARMACY SERVICE INC 4600 N HANLEY RD
SAINT LOUISMO6313410/01/2023  
CH092890EXPRESS SCRIPTS PHARMACY, INC.DBA EXPRESS SCRIPTS 2040 ROUTE 130 NORTH
BURLINGTONNJ0801610/01/2023  
CH092890EXPRESS SCRIPTS PHARMACY, INC.DBA EXPRESS SCRIPTS 4750 E. 450 S.
WHITESTOWNIN4607510/01/2023  
CH092890GENOA HEALTHCARE LLC915 AIRWAY AVE STE B
KINGMANAZ8640901/01/2024  
CH092890GENOA HEALTHCARE LLC2187 N VICKEY ST
FLAGSTAFFAZ8600401/01/2024  
CH092890GENOA HEALTHCARE LLC1101 NORTH CENTRAL AVE STE 102
PHOENIXAZ8500401/01/2024  
CH092890GENOA HEALTHCARE LLC404 W AERO DR
PAYSONAZ8554101/01/2024  
CH092890GENOA HEALTHCARE LLC1500 S WHITE MOUNTAIN ROAD BLDG 3 SUITE 302
SHOW LOWAZ8590101/01/2024  
CH092890GERMAN DOBSON CVS, L.L.C.DBA CVS/PHARMACY # 2412 60 E DEUCE OF CLUBS DR.
SHOW LOWAZ8590110/01/2017  
CH092890GERMAN DOBSON CVS, L.L.C.CVS PHARMACY # 16354 1650 S MILTON RD
FLAGSTAFFAZ8600110/01/2019  
CH09289EGERMAN DOBSON CVS, L.L.C.DBA CVS/PHARMACY # 2412 60 E DEUCE OF CLUBS DR.
SHOW LOWAZ8590107/01/2024  
CH092890OPTUM INFUSION SERVICES 201, INC.5700 DOT COM CT STE 1030
OVIEDOFL32765-340001/01/2024 10/15/2023
CH092890OPTUM PHARMACY 700, LLC5700 DOT COM CT, STE 1000
OVIEDOFL3276501/01/2024  
CH092890OPTUM PHARMACY 701, LLC8131 W BOSTIAN RD STE A350
WOODINVILLEWA98072-502901/01/2024  
CH092890OPTUM PHARMACY 701, LLC1830 S HORNE
MESAAZ8520410/01/2024 04/09/2025
CH092890OPTUM PHARMACY 701, LLC1830 S HORNE
MESAAZ8520407/01/2025  
CH092890OPTUM PHARMACY 702, LLC1050 PATROL RD
JEFFERSONVILLEIN4713001/01/2024  
CH092890OPTUM PHARMACY 704, INC.5627 UNIVERSITY HTS STE 108
SAN ANTONIOTX7824901/01/2024  
CH092890OPTUM PHARMACY 707, INC4900 RIVERGRADE RD STE E110
IRWINDALECA91706-140101/01/2024  
CH092890OPTUMRXOPTUMRX INC 6800 W 115TH ST STE 600
OVERLAND PARKKS66211-983801/01/2024  
CH092890PROCARE PHARMACY DIRECT, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 105 MALL BOULEVARD
MONROEVILLEPA1514610/01/2021  
CH092890PROCARE PHARMACY, L.L.C.DBA CVS/PHARMACY OR CARELONRX SPECIALTY ONE WATERFRONT PLAZA
500 ALA MOANA BLVD., BLDG 1
HONOLULUHI9681310/01/2021  
CH092890PROCARE PHARMACY, L.L.C.DBA: CVS/PHARMACY #2909 1521 4TH AVE., SOUTH
BIRMINGHAMAL3523310/01/2021  
CH092890PROCARE PHARMACY, L.L.C.DBA CVS/PHARMACY #2923 3250 HARDEN ST. EXT. SUITE #300
COLUMBIASC2920310/01/2021  
CH092890RAINA RX LLCDBA ROUTE 300 PHARMACY 1208 ROUTE 300
SUITE 103
NEWBURGHNY1255001/01/2025  
CH092890RIVER MEDICAL PHARMACY LLC4752 RESEARCH DR
SAN ANTONIOTX78240-500201/01/2025  
CH092890SAFEWAY INCSAFEWAY PHARMACY #1747 1031 NORTH HIGHWAY 89
CHINO VALLEYAZ8632304/05/2011 04/20/2023
CH092890SAFEWAY INCSAFEWAY PHARMACY #1639 637 W ROUTE 66
WILLIAMSAZ8604604/05/2011  
CH092890SAFEWAY INCSAFEWAY PHARMACY #3189 702 WEST HOPI DRIVE
HOLBROOKAZ8602504/05/2011  
CH092890SAFEWAY INCSAFEWAY PHARMACY #1733 900 W. DEUCE OF CLUBS
SHOW LOWAZ8590110/15/2012  
CH092890SAFEWAY INCSAFEWAY PHARMACY #0239 1601 NORTH PARK DRIVE
WINSLOWAZ8604704/01/2013  
CH092890SAFEWAY INCSAFEWAY PHARMACY #0216 1650 MCCULLOCH BLVD.
LAKE HAVASU CITYAZ8640307/01/2013  
CH092890SAFEWAY INCSAFEWAY PHARMACY #0248 1751 HIGHWAY 95
BULLHEAD CITYAZ8644210/01/2017  
CH092890SAFEWAY INCSAFEWAY PHARMACY #0270 4910 N HIGHWAY 89
FLAGSTAFFAZ8600410/01/2017  
CH092890SAFEWAY INCSAFEWAY PHARMACY #1225 1500 E CEDAR AVE
FLAGSTAFFAZ86004-164110/01/2017  
CH092890SAFEWAY INCSAFEWAY PHARMACY #1536 401 EAST HIGHWAY260
PAYSONAZ8554110/01/2017  
CH092890SAFEWAY INCSAFEWAY PHARMACY #2069 20 E. WHITE MOUNTAIN RD.
LAKESIDEAZ8592910/01/2017  
CH092890SAFEWAY INCSAFEWAY PHARMACY #1887 3970 STOCKTON HILL ROAD
KINGMANAZ8640910/01/2017  
CH092890SAFEWAY INCSAFEWAY PHARMACY #2028 1201 SOUTH PLAZA WAY
FLAGSTAFFAZ8600210/01/2017  
CH09289BSAFEWAY INCSAFEWAY PHARMACY #1639 637 W ROUTE 66
WILLIAMSAZ8604604/05/2011 01/01/2021
CH09289BSAFEWAY INCSAFEWAY PHARMACY #1747 1031 NORTH HIGHWAY 89
CHINO VALLEYAZ8632303/09/2011 01/01/2021
CH09289CSAFEWAY INCSAFEWAY PHARMACY #1747 1031 NORTH HIGHWAY 89
CHINO VALLEYAZ8632303/09/2011  
CH09289DSAFEWAY INCSAFEWAY PHARMACY #3189 702 WEST HOPI DRIVE
HOLBROOKAZ8602504/05/2011  
CH09289ISAFEWAY INCSAFEWAY PHARMACY #1747 1031 NORTH HIGHWAY 89
CHINO VALLEYAZ8632303/09/2011 04/01/2024
CH09289ISAFEWAY INCSAFEWAY PHARMACY #1639 637 W ROUTE 66
WILLIAMSAZ8604612/13/2010 04/01/2024
CH09289MSAFEWAY INCSAFEWAY PHARMACY #1747 1031 NORTH HIGHWAY 89
CHINO VALLEYAZ8632304/02/2011  
CH09289MSAFEWAY INCSAFEWAY PHARMACY #3189 702 WEST HOPI DRIVE
HOLBROOKAZ8602504/05/2011  
CH09289MSAFEWAY INCSAFEWAY PHARMACY #1639 637 W ROUTE 66
WILLIAMSAZ8604604/05/2011  
CH09289GSAFEWAY INCSAFEWAY PHARMACY #0239 1601 NORTH PARK DRIVE
WINSLOWAZ8604707/01/2024  
CH092890SANTA BARBARA SPECIALTY PHARMACY LLC4690 CARPINTERIA AVE STE B
CARPINTERIACA9301301/01/2025  
CH092890SMITH'S FOOD & DRUG CTRSSMITHS PHARMACY #0190 3490 STOCKTON HILL RD
KINGMANAZ8640910/01/2017  
CH092890SMITH'S FOOD & DRUG CTRSDBA SMITH'S FOOD & DRUG #191 1775 LAKESIDE DR
BULLHEAD CITYAZ8644210/01/2017  
CH092890SMITH'S FOOD AND DRUGDBA FRY'S FOOD AND DRUG #104 201 NORTH SWITZER CANYON DRIVE
FLAGSTAFFAZ8600110/01/2017  
CH092890SMITHS FOOD & DRUG CENTER INCSMITHS FOOD & DRUG #188 80 N. ACOMA BLVD.
LAKE HAVASU CITYAZ8640310/01/2017  
CH092890ST JOHNS DRUG1155 W. CLEVELAND PO BOX 517
ST JOHNSAZ8593610/31/2012  
CH092890UPTOWN PHARMACY OF KINGMAN INC.UPTOWN DRUG 2820 E ANDY DEVINE AVE
KINGMANAZ8640110/01/2024  
CH092890WADHAMS APOTHECARY3100 N WEST ST STE 200A
FLAGSTAFFAZ86004-165104/05/2011 09/01/2015
CH09289MWADHAMS APOTHECARY3100 N WEST ST STE 200A
FLAGSTAFFAZ86004-165104/05/2011  
CH092890WAL-MART CENTRAL FILL 10-2670608 SPRING HILL DR # 3 SUITE 300
SPRINGTX7738610/01/2017  
CH092890WAL-MART PHARMACY 10-11752750 WOODLANDS VILLAGE BLVD.
FLAGSTAFFAZ8600110/01/2017  
CH092890WAL-MART PHARMACY 10-12305401 S. WHITE MOUNTAIN ROAD
SHOW LOWAZ8590110/01/2017  
CH092890WAL-MART PHARMACY 10-12992003 E. RODEO DRIVE
COTTONWOODAZ8632610/01/2017  
CH092890WAL-MART PHARMACY 10-1328700 MIKE'S PIKE ST
WINSLOWAZ8604710/01/2017  
CH092890WAL-MART PHARMACY 10-13645695 HWY 95 NORTH
LAKE HAVASU CITYAZ8640410/01/2019  
CH092890WAL-MART PHARMACY 10-1369300 NORTH BEELINE HWY.
PAYSONAZ8554110/01/2017  
CH09289PWAL-MART PHARMACY 10-1369300 NORTH BEELINE HWY.
PAYSONAZ8554107/01/2024  
CH092890WAL-MART PHARMACY 10-13702840 HWY 95
BULLHEAD CITYAZ8644210/01/2017  
CH092890WAL-MART PHARMACY 10-20513396 NO. STOCKTON HILL RD.
KINGMANAZ8640910/01/2017  
CH092890WAL-MART PHARMACY 10-42522601 E HUNTINGTON DR.
FLAGSTAFFAZ8600410/01/2017  
CH092890WAL-MART PHARMACY 10-59979600 PARKSOUTH CT. SUITE 100
ORLANDOFL3283710/01/2017  
CH092890WALGREEN ARIZONA DRUG CO.DBA: WALGREENS # 03245 3487 N STOCKTON HILL RD
KINGMANAZ8640901/01/2014  
CH092890WALGREEN ARIZONA DRUG CO.DBA: WALGREENS # 05090 5160 S WHITE MOUNTAIN RD
SHOW LOWAZ8590101/01/2014  
CH092890WALGREEN ARIZONA DRUG CO.DBA: WALGREENS # 05208 25 LAKE HAVASU AVE S
LAKE HAVASU CITYAZ8640301/01/2014  
CH092890WALGREEN ARIZONA DRUG CO.DBA: WALGREENS # 05221 1025 S MILTON RD
FLAGSTAFFAZ8600101/01/2014  
CH092890WALGREEN ARIZONA DRUG CO.DBA: WALGREENS #09571 1020 N HIGHWAY 89
CHINO VALLEYAZ8632301/01/2014  
CH092890WALGREEN ARIZONA DRUG CO.DBA: WALGREENS #12880 1925 E ANDY DEVINE AVE
KINGMANAZ8640101/01/2014  
CH092890WALGREEN ARIZONA DRUG CO.DBA: WALGREENS #15206 2610 E. ROUTE 66
FLAGSTAFFAZ8600401/01/2014  
CH092890WALGREEN ARIZONA DRUG CO.DBA: WALGREENS # 03913 2360 HIGHWAY 95
BULLHEAD CITYAZ8644204/01/2015  
CH092890WALGREEN ARIZONA DRUG CO.DBA: WALGREENS # 06533 100 S BEELINE HWY
PAYSONAZ85541-480904/01/2015  
CH092890WALGREEN ARIZONA DRUG CO.WALGREENS CENTRAL FILL #21372 120 N 83RD AVE
STE 200
TOLLESONAZ8535310/01/2021  
CH092890WALGREENS MAIL SERVICE, INC.8350 S RIVER PARKWAY
TEMPEAZ8528401/01/2014  
CH092890WALGREENS MAIL SERVICE, LLCWALGREENS MAIL SERVICE #03397 8350 S RIVER PARKWAY
TEMPEAZ8528401/01/2018  
CH092890WALGREENS.COM, INC.DBA: WALGREENS 2225 S. PRICE ROAD
CHANDLERAZ8528601/01/2018  
CH092890WALMART PHARMACY 10-42035210 S. HIGHWAY 95
FORT MOHAVEAZ86426-727110/01/2019  
CH092890WALMART PHARMACY 10-4355715 N. MAIN ST
TAYLORAZ8593910/01/2019  
CH092890WALMART PHARMACY 10-51692252 NORTH 8TH STREET
SUITE A
ROGERSAR7275601/01/2024  
CH092890WESTERN DRUG INC106 EAST MAIN P.O.BOX 111
SPRINGERVILLEAZ8593810/31/2012  
CH09289JWESTERN DRUG INC106 EAST MAIN P.O.BOX 111
SPRINGERVILLEAZ8593807/01/2024  
CH092890WHITE MOUNTAIN PHARMACYN & R BRYCE ENTERPRISES LLC 4461 S WHITE MOUNTAIN RD STE E1
SHOW LOWAZ85901-778210/01/2019  
History
SectionFieldActionActivityValue BeforeValue AfterTimestamp 
AddressesShipping AddressDeleteRecertificationNorth Country HealthCare 126 E Main Street Suite B Payson, AZ 85541 2/25/2025 10:20 AM
AddressesShipping AddressInsertRecertification North Country HealthCare - Payson 126 E Main Street Suite B Payson, AZ 855412/25/2025 10:20 AM
Medicaid BillingMedicaid: NumberDeleteRecertification889501 (AZ) 2/25/2025 10:20 AM
Medicaid BillingMedicaid: NumberDeleteRecertification439184 (AZ) 2/25/2025 10:20 AM
Medicaid BillingNPI: NumberInsertRecertification 10535872612/25/2025 10:20 AM
Medicaid BillingNPI: StateInsertRecertification AZ2/25/2025 10:20 AM
DetailsLast Recertification DateUpdateRecertification2/20/2024 2:05:23 PM2/25/2025 10:20:49 AM2/25/2025 10:20 AM
ContactsPrimary ContactUpdateGroup Change RequestCHEN, KIMBERLY DIRECTOR OF PHARMACY North Country HealthCare 9285229572Kurtz, Andrew Director of Pharmacy North Country HealthCare 928522107312/23/2024 7:43 AM
DetailsLast Recertification DateUpdateRecertification2/15/2023 10:59:45 AM2/20/2024 2:05:23 PM2/20/2024 2:05 PM
DetailsEntity SubnameUpdateChange RequestPayson ClinicNORTH COUNTRY HEALTHCARE- PAYSON10/18/2023 3:59 PM
DetailsLast Recertification DateUpdateRecertification2/9/2022 4:10:08 PM2/15/2023 10:59:45 AM2/15/2023 10:59 AM
DetailsLast Recertification DateUpdateRecertification2/4/2021 4:17:30 PM2/9/2022 4:10:08 PM2/9/2022 4:10 PM
AddressesShipping AddressInsertChange Request North Country HealthCare 126 E Main Street Suite B Payson, AZ 8554111/4/2021 11:01 AM
AddressesShipping AddressInsertChange Request North Country HealthCare 2920 N 4th Street Flagstaff, AZ 8600411/4/2021 11:01 AM
AddressesShipping AddressInsertChange Request North Country HealthCare 1 Clinic Road Grand Canyon, AZ 8602311/4/2021 11:01 AM
AddressesShipping AddressInsertChange Request North Country HealthCare 1510 Stockton Hill Road Kingman, AZ 8640111/4/2021 11:01 AM
Medicaid BillingNPI: StateUpdateRecertification AZ2/4/2021 4:17 PM
Medicaid BillingNPI: StateUpdateRecertification AZ2/4/2021 4:17 PM
Medicaid BillingNPI: StateUpdateRecertification AZ2/4/2021 4:17 PM
DetailsLast Recertification DateUpdateRecertification1/29/2020 4:59:12 PM2/4/2021 4:17:30 PM2/4/2021 4:17 PM
DetailsLast Recertification DateUpdateRecertification2/21/2019 11:39:07 AM1/29/2020 4:59:12 PM1/29/2020 4:59 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False8/8/2019 6:53 PM
Medicaid BillingMedicaid: NumberInsertChange Request 4970948/8/2019 6:53 PM
Medicaid BillingMedicaid: StateInsertChange Request AZ8/8/2019 6:53 PM
AddressesMain AddressUpdateChange Request 708 S COEUR D ALENE LN PAYSON, AZ 85541-5662 126 E Main St, Ste B PAYSON, AZ 855415/22/2019 4:11 PM
DetailsIs Authorizing Official EHB DataUpdateChange RequestFalse 5/22/2019 4:11 PM
DetailsLast Recertification DateUpdateRecertification2/12/2018 5:38:46 PM2/21/2019 11:39:07 AM2/21/2019 11:39 AM
DetailsLast Recertification DateUpdateRecertification2/14/2017 12:00:00 AM2/12/2018 5:38:46 PM2/12/2018 5:38 PM
ContactsPrimary ContactUpdate CHEN, KIMBERLY DIRECTOR OF PHARMACY 9285229572CHEN, KIMBERLY DIRECTOR OF PHARMACY North Country HealthCare 928522957210/9/2017 10:59 AM
ContactsAuthorizing OfficialUpdate NEWLAND, ANNE CEO 9285229564NEWLAND, ANNE CEO North Country HealthCare 928522956410/4/2017 2:04 PM
AddressesMain AddressInsert   708 S COEUR D ALENE LN PAYSON, AZ 85541-56628/13/2017 9:48 AM
AddressesBilling AddressInsert  NORTH COUNTRY HEALTHCARE PO BOX 3630 FLAGSTAFF, AZ 860038/13/2017 9:48 AM
ContactsAuthorizing OfficialInsert  NEWLAND, ANNE CEO 92852295648/13/2017 9:48 AM
ContactsSigned ByInsert  ROGGENBUCK, ANN CEO 92852295628/13/2017 9:48 AM
ContactsPrimary ContactUpdate CHRISTOFF, KIMBERLY DIRECTOR OF PHARMACY 9285229572CHEN, KIMBERLY DIRECTOR OF PHARMACY 92852295728/13/2017 9:48 AM
DetailsLast Recertification DateUpdate 2/22/2016 12:00:00 AM2/14/2017 12:00:00 AM2/14/2017 1:48 PM
ContactsPrimary ContactInsert  CHRISTOFF, KIMBERLY DIRECTOR OF PHARMACY 92852295722/22/2016 12:35 PM
DetailsLast Recertification DateUpdate 3/10/2015 12:00:00 AM2/22/2016 12:00:00 AM2/22/2016 12:35 PM
Medicaid BillingMedicaid: Is PrimaryInsert  False3/10/2015 11:00 AM
Medicaid BillingMedicaid: NumberInsert  4391843/10/2015 11:00 AM
Medicaid BillingMedicaid: StateInsert  AZ3/10/2015 11:00 AM
Medicaid BillingMedicaid: Is PrimaryInsert  False3/10/2015 11:00 AM
Medicaid BillingMedicaid: NumberInsert  9079983/10/2015 11:00 AM
Medicaid BillingMedicaid: StateInsert  AZ3/10/2015 11:00 AM
Medicaid BillingMedicaid: Is PrimaryInsert  False3/10/2015 11:00 AM
Medicaid BillingMedicaid: NumberInsert  9682153/10/2015 11:00 AM
Medicaid BillingMedicaid: StateInsert  AZ3/10/2015 11:00 AM
Medicaid BillingNPI: NumberInsert  16493344423/10/2015 11:00 AM
DetailsLast Recertification DateUpdate  3/10/2015 12:00:00 AM3/10/2015 11:00 AM
DatesParticipating Approval DateUpdate  7/23/2014 12:00:00 AM7/23/2014 2:55 PM
DetailsStateUpdate PendingActive7/23/2014 2:55 PM
DatesStart DateUpdate  10/1/2014 12:00:00 AM7/23/2014 2:55 PM
Details340B IDUpdate ONLINE_REG_44714CH09289P7/23/2014 6:27 AM
Details340B IDUpdate ONLINE_REGONLINE_REG_447147/8/2014 7:01 PM
Medicaid BillingMedicaid: Is PrimaryInsert  False7/8/2014 7:01 PM
Medicaid BillingMedicaid: NumberInsert  8895017/8/2014 7:01 PM
Medicaid BillingMedicaid: StateInsert  AZ7/8/2014 7:01 PM
Medicaid BillingMedicaid: Is PrimaryInsert  False7/8/2014 7:01 PM
Medicaid BillingMedicaid: NumberInsert  4330797/8/2014 7:01 PM
Medicaid BillingMedicaid: StateInsert  AZ7/8/2014 7:01 PM
Medicaid BillingNPI: NumberInsert  10931467557/8/2014 7:01 PM
Medicaid BillingNPI: NumberInsert  10735834727/8/2014 7:01 PM
DetailsLast Recertification DateInsert   7/8/2014 7:01 PM
DetailsGrant NumberInsert  H80CS006517/8/2014 7:01 PM
Details340B IDInsert  ONLINE_REG7/8/2014 7:01 PM
DetailsIs Authorizing Official EHB DataInsert  False7/8/2014 7:01 PM
DatesLast Date That 340B Drugs PurchasedInsert   7/8/2014 7:01 PM
DetailsMedicare Provider NumberInsert   7/8/2014 7:01 PM
DetailsEntity NameInsert  NORTH COUNTRY HEALTHCARE, INC.7/8/2014 7:01 PM
DetailsProgram CodeInsert  CH7/8/2014 7:01 PM
DetailsEntity SubnameInsert  Payson Clinic7/8/2014 7:01 PM
DatesParticipating Approval DateInsert   7/8/2014 7:01 PM
DetailsStateInsert  Pending7/8/2014 7:01 PM
DatesRegistration DateInsert  7/8/2014 12:00:00 AM7/8/2014 7:01 PM
DatesSigned By DateInsert  7/8/2014 12:00:00 AM7/8/2014 7:01 PM
DatesStart DateInsert   7/8/2014 7:01 PM
TerminationsTermination CommentsInsert   7/8/2014 7:01 PM
TerminationsTermination DateInsert   7/8/2014 7:01 PM
TerminationsTermination Effective DateInsert   7/8/2014 7:01 PM
TerminationsTermination ReasonInsert   7/8/2014 7:01 PM