Covered Entity Details

DSH030014A JOHN C LINCOLN MEDICAL CENTER (Terminated) - information as of 5/1/2025 11:50:52 PM

Main Details

Name

JOHN C LINCOLN MEDICAL CENTER

Subdivision Name

Outpatient / Medical Imaging

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH030014A

Medicare Provider Number

030014

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/14/2015

Participating Start Date

7/1/2015

Participating Approval Date

5/29/2015

Last Recertification Date

8/12/2016

Termination Date
Termination Reason

1/1/2018
Business decision by the Covered Entity

Contacts

Authorizing Official

HonorHealth
Gary Baker, SVP-CEO-HOSPITAL
(480) 583-0803

Primary Contact

HonorHealth
Kristjon Lindgren, 340B Program Manager
(602) 870-6060 Ext: 331353

Addresses

Street Address

9250 N 3rd St #1002
Phoenix, AZ 85020-2412

Billing Address
Same as Street Address

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	022241
		1770690695

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH030014A	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	Outpatient / Medical Imaging	9250 N 3rd St #1002	Phoenix	AZ	Terminated
DSH030014AA	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Wound Clinic OP	9202 N 2nd St #101	Phoenix	AZ	Active
DSH030014AB	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Pulmonary Hypertension Clinic	9250 N 3rd St #2030	Phoenix	AZ	Active
DSH030014AC	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Virginia G Piper CCN-Apache Junction	750 S Ironwood Dr #102	Apache Junction	AZ	Terminated
DSH030014AD	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Biltmore	2222 E Highland Ave #400	Phoenix	AZ	Active
DSH030014AE	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Tempe	7695 S Research Dr	Tempe	AZ	Active
DSH030014AF	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - GynOnc Shea	10197 N 92nd St #101	Scottsdale	AZ	Active
DSH030014AG	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	BMT Outpatient	10460 N 92nd St #300	Scottsdale	AZ	Active
DSH030014AH	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HHRI Oncology Clinical Trials	10510 N 92nd St	Scottsdale	AZ	Active
DSH030014AJ	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Home Health	3634 N Drinkwater Blvd	Scottsdale	AZ	Active
DSH030014B	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	John C Lincoln Outpatient Imaging - 27th Ave. / Medical Imaging	19636 N 27th Ave. #LL1	Phoenix	AZ	Terminated
DSH030014C	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	OR Outpatient Surgery	9250 N 3rd St #1001	Phoenix	AZ	Active
DSH030014D	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	John C Lincoln-Tatum / Outpatient Medical Imaging	18404 N Tatum Blvd. #103	Phoenix	AZ	Terminated
DSH030014E	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Infusion Center-Glendale	6220 W Bell Rd #110	Glendale	AZ	Active
DSH030014F	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	Pharmacy Care Coordination	9109 North Central Avenue	Phoenix	AZ	Terminated
DSH030014G	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	Comprehensive Care Clinic / Outpatient Center	9225 North 3rd Street	Phoenix	AZ	Terminated
DSH030014H	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	Comprehensive Care Center / Senior Support Services	9225 N 3rd St	Phoenix	AZ	Terminated
DSH030014J	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	Happy Valley Infusion Care Clinic	10230 W. Happy Valley Parkway	Peoria	AZ	Terminated
DSH030014K	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - John C. Lincoln	9250 N 3rd St #3010	Phoenix	AZ	Active
DSH030014L	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Deer Valley	19646 N 27th Ave #301	Phoenix	AZ	Active
DSH030014M	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	OR Preop/PACU - OP	9250 N 3rd St #1001	Phoenix	AZ	Active
DSH030014N	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Osborn	3621 N Wells Fargo Ave	Scottsdale	AZ	Active
DSH030014P	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Gilbert	3645 S Rome St #209	Gilbert	AZ	Active
DSH030014Q	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Chandler	1110 S Dobson Rd #1	Chandler	AZ	Active
DSH030014R	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Thompson Peak	20745 N Scottsdale Rd #115	Scottsdale	AZ	Active
DSH030014S	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Avondale	10320 W McDowell Rd Bldg H	Avondale	AZ	Active
DSH030014T	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Surprise	14674 W Mountain View Blvd #105	Surprise	AZ	Active
DSH030014U	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Virginia G Piper Cancer Care Network-Wickenburg	519 Rose Ln	Wickenburg	AZ	Terminated
DSH030014V	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Fountain Hills	16716 E Palisades Blvd #103	Fountain Hills	AZ	Active
DSH030014W	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Glendale	15000 N 83rd Ave #300	Peoria	AZ	Active
DSH030014X	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Shea	10460 N 92nd St #200 and #400	Scottsdale	AZ	Active
DSH030014Y	Child	DSH	JOHN C. LINCOLN MEDICAL CENTER	JCLMC Infusion Center	3501 N Scottsdale Rd #136	Scottsdale	AZ	Terminated
DSH030014Z	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Infusion Center - NSI	7242 E Osborn Rd #340, #400, and #500	Scottsdale	AZ	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	AO Change Request	Post, Kim EVP Chief Operations Officer HonorHealth 4805875087	Baker, Gary SVP-CEO-HOSPITAL HonorHealth 4805830803	8/26/2019 6:42 AM
Contacts	Authorizing Official	Update	Profile Change Request	Post, Kim SVP-CEO HOS_CHF CLIN OFC HonorHealth 4805875087	Post, Kim EVP Chief Operations Officer HonorHealth 4805875087	7/19/2019 12:28 PM
Contacts	Authorizing Official	Update	Change Request	Pope, Alice Chief Financial Officer HonorHealth 4808825544	Post, Kim SVP-CEO HOS_CHF CLIN OFC HonorHealth 4805875087	7/1/2019 8:33 AM
Contacts	Primary Contact	Update	Profile Change Request	Lindgren, Kristjon 340B Program Supervisor HonorHealth 6028706060-331353	Lindgren, Kristjon 340B Program Manager HonorHealth 6028706060-331353	4/5/2019 2:38 PM
Contacts	Authorizing Official	Update	Change Request	Moravec, Susan AVP, Chief of Phamacy HonorHealth 4808825941	Pope, Alice Chief Financial Officer HonorHealth 4808825544	2/23/2018 3:14 PM
Details	State	Update		To Be Terminated	Terminated	1/1/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		11/10/2017 12:00:00 AM	11/8/2017 1:02 PM
Details	State	Update	Recertification	Active	To Be Terminated	11/8/2017 1:02 PM
Terminations	Termination Date	Update	Recertification		1/1/2018 12:00:00 AM	11/8/2017 1:02 PM
Terminations	Termination Effective Date	Update	Recertification		12/31/2017 12:00:00 AM	11/8/2017 1:02 PM
Terminations	Termination Reason	Update	Recertification		Business decision by the Covered Entity	11/8/2017 1:02 PM
Details	Entity Name	Update	Recertification	JOHN C LINCOLN HOSP-NORTH MOUNTAIN	JOHN C LINCOLN MEDICAL CENTER	11/8/2017 12:26 PM
Contacts	Primary Contact	Insert	Change Request		Lindgren, Kristjon 340B Program Supervisor HonorHealth 6028706060-331353	10/13/2017 2:06 PM
Contacts	Authorizing Official	Update		Moravec, Susan AVP, Chief of Phamacy 4808825941	Moravec, Susan AVP, Chief of Phamacy HonorHealth 4808825941	10/3/2017 3:04 PM
Contacts	Authorizing Official	Insert			Moravec, Susan AVP, Chief of Phamacy 4808825941	8/14/2017 6:22 PM
Contacts	Signed By	Insert			de Jesus, Josenor Network Associate Vice President of Pharmacy Svcs. 4803233203	7/26/2017 2:04 PM
Addresses	Main Address	Insert			9250 N 3rd St #1002 Phoenix, AZ 85020-2412	7/21/2017 1:34 PM
Details	Last Recertification Date	Update		8/14/2015 12:00:00 AM	8/12/2016 12:00:00 AM	8/12/2016 9:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/15/2016 11:08 AM
Medicaid Billing	Medicaid: Number	Insert			022241	3/15/2016 11:08 AM
Medicaid Billing	Medicaid: State	Insert			AZ	3/15/2016 11:08 AM
Medicaid Billing	NPI: Number	Insert			1770690695	3/15/2016 11:08 AM
Details	Last Recertification Date	Update			8/14/2015 12:00:00 AM	8/14/2015 1:58 PM
Dates	Participating Approval Date	Update			5/29/2015 12:00:00 AM	5/29/2015 3:21 PM
Details	State	Update		Pending	Active	5/29/2015 3:21 PM
Dates	Start Date	Update			7/1/2015 12:00:00 AM	5/29/2015 3:21 PM
Details	Entity Subname	Update		John C Lincoln Outpatient Medical Imaging / Medical Imaging	Outpatient / Medical Imaging	5/20/2015 4:31 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_51479	DSH030014A	5/1/2015 12:25 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_51479	4/14/2015 2:32 PM
Details	Last Recertification Date	Insert				4/14/2015 2:32 PM
Details	Grant Number	Insert				4/14/2015 2:32 PM
Details	340B ID	Insert				4/14/2015 2:32 PM
Details	Is Authorizing Official EHB Data	Insert				4/14/2015 2:32 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/14/2015 2:32 PM
Details	Medicare Provider Number	Insert			030014	4/14/2015 2:32 PM
Details	Entity Name	Insert			JOHN C LINCOLN HOSP-NORTH MOUNTAIN	4/14/2015 2:32 PM
Details	Program Code	Insert			DSH	4/14/2015 2:32 PM
Details	Entity Subname	Insert			John C Lincoln Outpatient Medical Imaging / Medical Imaging	4/14/2015 2:32 PM
Dates	Participating Approval Date	Insert				4/14/2015 2:32 PM
Details	State	Insert			Pending	4/14/2015 2:32 PM
Dates	Registration Date	Insert			4/14/2015 12:00:00 AM	4/14/2015 2:32 PM
Dates	Signed By Date	Insert			4/14/2015 12:00:00 AM	4/14/2015 2:32 PM
Dates	Start Date	Insert				4/14/2015 2:32 PM
Terminations	Termination Comments	Insert				4/14/2015 2:32 PM
Terminations	Termination Date	Insert				4/14/2015 2:32 PM
Terminations	Termination Effective Date	Insert				4/14/2015 2:32 PM
Terminations	Termination Reason	Insert				4/14/2015 2:32 PM