Covered Entity Details

CH09307H MOUNTAIN PARK HEALTH CENTER (Terminated) - information as of 6/27/2025 12:33:52 AM

Main Details

Name

MOUNTAIN PARK HEALTH CENTER

Subdivision Name

Mountain Park Health Center - Sunrise

Type

HRSA-Funded Health Center

Site ID

BPS-H80-015312

340B ID

CH09307H

Grant Number

H80CS00141

Additional Details

Current Program Status

Terminated

Registration Date

10/8/2015

Participating Start Date

1/1/2016

Participating Approval Date

10/16/2015

Last Recertification Date

2/13/2018

Termination Date
Termination Reason

7/1/2018
Site closure

Contacts

Authorizing Official

Mountain Park Health Center
John R. Swagert, CEO
(602) 323-3470

Primary Contact

Mountain Park Health Center
Mary Soto, Associate Director of Pharmacy
(602) 586-3026

Addresses

Street Address

17624 N. 31st Avenue
Phoenix, AZ 85053

Billing Address

Mountain Park Health Center - Central Office
3003 N. Central Ave
Suite 1600
Phoenix, AZ 85012-2908

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
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	074984
		1386027852,1467630012,1578741120

Shipping Addresses

Shipping Address 1

Mountain Park Health Center- Maryvale
6601 W. Thomas Rd.
Phoenix, AZ 85033

Shipping Address 2

Mountain Park Health Center-Baseline
635 E. Baseline Rd.
Phoenix, AZ 85042

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.

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH093070	Active	BPS-H80-000998	MOUNTAIN PARK HEALTH CENTER	Mountain Park Health Center - Baseline	635 E Baseline Rd	Phoenix	AZ
CH09307B	Active	BPS-H80-010130	MOUNTAIN PARK HEALTH CENTER	Mountain Park Health Center - Maryvale	6601 W. Thomas	Phoenix	AZ
CH09307C	Active	BPS-H80-010170	MOUNTAIN PARK HEALTH CENTER	Mountain Park Health Center - Goodyear	140 N Litchfield Rd Ste 200	Goodyear	AZ
CH09307D	Active	BPS-H80-014363	MOUNTAIN PARK HEALTH CENTER	Mountain Park Health Center - Gateway	3830 E VAN BUREN ST	PHOENIX	AZ
CH09307E	Terminated	BPS-H80-005333	MOUNTAIN PARK HEALTH CENTER	MOUNTAIN PARK HEALTH CENTER	2702 N. 3rd St.	Phoenix	AZ
CH09307F	Active	BPS-H80-019497	MOUNTAIN PARK HEALTH CENTER	Mountain Park Health Center - Tempe	1840 E Broadway Rd	Tempe	AZ
CH09307G	Active	BPS-H80-015223	MOUNTAIN PARK HEALTH CENTER	Mountain Park Health Center - Christown	5517 N 17th Ave	Phoenix	AZ
CH09307H	Terminated	BPS-H80-015312	MOUNTAIN PARK HEALTH CENTER	Mountain Park Health Center - Sunrise	17624 N. 31st Avenue	Phoenix	AZ
CH09307J	Active	BPS-H80-015311	MOUNTAIN PARK HEALTH CENTER	Mountain Park Health Center - Atkinson	4222 N 51st Ave	Phoenix	AZ
CH09307K	Active	BPS-H80-021683	MOUNTAIN PARK HEALTH CENTER	Mountain Park Health Center - Central Office	3003 N Central Ave	Phoenix	AZ
CH09307L	Active	BPS-H80-031454	Mountain Park Health Center	Mountain Park Health Center - 303 Baseline	303 E Baseline Rd	Phoenix	AZ
CH09307M	Terminated	BPS-H80-018626	Mountain Park Health Center	Mountain Park Health Center - 303 E Baseline Suite 300	303 East Baseline Road	Phoenix	AZ
CH09307N	Active	BPS-H80-030110	Mountain Park Health Center	Mountain Park Health Center - Goodyear Suite 106	140 N Litchfield Rd Ste 106	Goodyear	AZ
CH09307P	Active	BPS-H80-030080	Mountain Park Health Center	Mountain Park Health Center - Goodyear Suite 102	140 N Litchfield Rd Ste 102	Goodyear	AZ
CH09307Q	Terminated	BPS-H80-030510	Mountain Park Health Center	Temporary - Mountain Park Health Center 325 E Baseline	325 E Baseline Rd	Phoenix	AZ
CH09307R	Terminated	BPS-H80-031041	Mountain Park Health Center	Temporary Site- Mountain Park Health Center	303 E Baseline Rd Ste 105	Phoenix	AZ
CH09307S	Active	BPS-H80-032975	Mountain Park Health Center	Mountain Park Health Center - Balsz	1300 N 48th Street	Phoenix	AZ
CH09307T	Active	BPS-H80-021358	Mountain Park Health Center	Mountain Park Health Center - Goodyear Suite 100	140 N Litchfield Rd Ste 100	Goodyear	AZ
CH09307U	Active	BPS-H80-035716	Mountain Park Health Center	Mountain Park Health Center - 325 E Baseline	325 E Baseline Rd	Phoenix	AZ
CH09307V	Active	BPS-H80-033849	Mountain Park Health Center	Mountain Park Health Center - Glendale	6975 W Glendale Ave	Glendale	AZ

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH093070	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/01/2025
CH093070	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/01/2025
CH093070	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/01/2025
CH093070	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/01/2025
CH093070	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/01/2025
CH093070	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	04/01/2025
CH093070	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	07/01/2024
CH093070	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09327	6021 S CENTRAL AVE	PHOENIX	AZ	85042	07/01/2021	08/26/2023
CH093070	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03383	7550 SOUTH 19TH AVE.	PHOENIX	AZ	85041	07/01/2021
CH093070	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09314	3440 WEST GLENDALE AVE	PHOENIX	AZ	85051	07/01/2021
CH093070	ARIZONA CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 09225	2406 EAST THOMAS RD.	PHOENIX	AZ	85016	01/01/2024
CH093070	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/01/2024
CH093070	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/01/2024
CH093070	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/01/2024
CH093070	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/01/2024
CH093070	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/01/2024
CH093070	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/01/2024
CH093070	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/01/2024
CH093070	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/01/2024
CH093070	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/01/2024
CH093070	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/01/2024
CH093070	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/01/2024
CH093070	GENOA HEALTHCARE LLC	3001 N 33RD AVE RM 210		PHOENIX	AZ	85017	04/01/2025
CH093070	GENOA HEALTHCARE LLC	1465 W CHANDLER BLVD, BLDG A, SUITE P		CHANDLER	AZ	85224	04/01/2025
CH093070	GENOA HEALTHCARE LLC	1255 W BASELINE RD STE 138		MESA	AZ	85202	04/01/2025
CH093070	GENOA HEALTHCARE LLC	1642 S PRIEST DR	BLDG 6, STE 101	TEMPE	AZ	85281	04/01/2025
CH093070	GENOA HEALTHCARE LLC	4909 E MCDOWELL RD		PHOENIX	AZ	85008	04/01/2025
CH093070	GENOA HEALTHCARE LLC	5222 E BASELINE RD STE 100		GILBERT	AZ	85234	04/01/2025
CH093070	GENOA HEALTHCARE LLC	4451 E OAK ST STE P1		PHOENIX	AZ	85008	04/01/2025
CH093070	GENOA HEALTHCARE LLC	3540 E BASELINE RD STE 150		PHOENIX	AZ	85042	04/01/2025
CH093070	GENOA HEALTHCARE LLC	4616 N 51ST AVE STE 108		PHOENIX	AZ	85031	04/01/2025
CH093070	GENOA HEALTHCARE LLC	1035 E JEFFERSON ST STE P1		PHOENIX	AZ	85034	04/01/2025
CH093070	GERMAN DOBSON CVS, L.L.C.	DBA CVS/PHARMACY #10229	280 N. AVONDALE BLVD	AVONDALE	AZ	85323	10/01/2020
CH093070	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 09222	4275 W. THOMAS RD.	PHOENIX	AZ	85019	10/01/2020
CH093070	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 07263	10707 W. CAMELBACK RD.	PHOENIX	AZ	85037	10/01/2020
CH093070	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 01744	6650 W. LOWER BUCKEYE RD.	PHOENIX	AZ	85043	10/01/2020
CH093070	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 06718	5835 W. INDIAN SCHOOL RD.	PHOENIX	AZ	85031	10/01/2020
CH093070	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 07872	7499 W. BETHANY HOME RD.	GLENDALE	AZ	85303	10/01/2020	06/06/2024
CH093070	GERMAN DOBSON CVS, L.L.C.	CVS PHARMACY # 17231	9830 W LOWER BUCKEYE RD	TOLLESON	AZ	85353	07/01/2021
CH093070	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 00040	1424 W BASELINE RD	TEMPE	AZ	85283	07/01/2021	06/01/2023
CH093070	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 07078	3303 S. RURAL	TEMPE	AZ	85282	07/01/2021	07/20/2023
CH093070	GERMAN DOBSON CVS, L.L.C.	CVS PHARMACY # 17418	5715 N 19TH AVE	PHOENIX	AZ	85015	07/01/2021
CH093070	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05778	4040 N. 19TH AVE.	PHOENIX	AZ	85015	07/01/2021
CH093070	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05892	5050 W. BASELINE RD.	LAVEEN	AZ	85339	07/01/2021
CH093070	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 03500	1625 N. 44TH ST.	PHOENIX	AZ	85008	07/01/2021
CH093070	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 07860	1615 E. BASELINE RD.	PHOENIX	AZ	85042	07/01/2021
CH093070	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 00033	1750 E BROADWAY RD	TEMPE	AZ	85282	07/01/2021
CH093070	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 06862	1850 W. DUNLAP AVE.	PHOENIX	AZ	85021	07/01/2021	11/15/2022
CH093070	GERMAN DOBSON CVS, L.L.C.	CVS PHARMACY # 17024	2140 E BASELINE RD	PHOENIX	AZ	85042	01/01/2023
CH093070	GERMAN DOBSON CVS, L.L.C.	CVS PHARMACY # 16292	7409 W VIRGINIA AVE	PHOENIX	AZ	85035	10/01/2023
CH093070	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 05950	855 E. ELLIOT ROAD	TEMPE	AZ	85284	01/01/2024
CH09307F	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 07860	1615 E. BASELINE RD.	PHOENIX	AZ	85042	07/01/2024
CH09307J	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 09222	4275 W. THOMAS RD.	PHOENIX	AZ	85019	07/01/2024
CH09307T	GERMAN DOBSON CVS, L.L.C.	DBA: CVS/PHARMACY # 06718	5835 W. INDIAN SCHOOL RD.	PHOENIX	AZ	85031	07/01/2024
CH093070	GOODYEAR CVS, L.L.C.	DBA: CVS/PHARMACY # 03749	2840 N. DYSART RD.	GOODYEAR	AZ	85395	07/01/2024
CH093070	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	04/01/2025
CH093070	OPTUM FRONTIER THERAPIES, LLC	325 W ATHERTON RD	SUITE 1	FLINT	MI	48507-2601	04/01/2025
CH093070	OPTUM PHARMACY 700, LLC	5700 DOT COM CT, STE 1000		OVIEDO	FL	32765	04/01/2025
CH093070	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	04/01/2025
CH093070	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	04/01/2025
CH093070	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/01/2025
CH093070	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	04/01/2025
CH093070	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	04/01/2025
CH093070	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	04/01/2025
CH093070	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	04/01/2025
CH093070	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/01/2024
CH093070	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/01/2024
CH093070	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/01/2024
CH093070	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #3129	1002 EAST MCDOWELL ROAD	PHOENIX	AZ	85006	07/01/2024
CH093070	SMITH'S FOOD & DRUG CENTER	DBA FRY'S FOOD AND DRUG #135	4505 E THOMAS ROAD	PHOENIX	AZ	85018	10/01/2016
CH093070	SMITH'S FOOD & DRUG CTRS	DBA FRY'S FOOD AND DRUG #126	6601 W. INDIAN SCHOOL RD.	PHOENIX	AZ	85033	10/01/2016
CH093070	SMITH'S FOOD & DRUG CTRS	DBA FRY'S FOOD STORES #89	11425 W BUCKEYE RD	AVONDALE	AZ	85323	10/01/2016
CH093070	SMITH'S FOOD AND DRUG CTR	DBA FRY'S FOOD & DRUG #101	3232 S MILL AVENUE	TEMPE	AZ	85282	10/01/2019
CH093070	SMITHS FOOD & DRUG CENTER	DBA FRYS FOOD & DRUG #87	5140 W BASELINE RD	LAVEEN	AZ	85339	10/01/2019
CH09307V	SMITHS FOOD & DRUG CENTER	DBA FRYS FOOD & DRUG #87	5140 W BASELINE RD	LAVEEN	AZ	85339	07/01/2024
CH093070	SMITHS FOOD & DRUG CENTERS	DBA FRYS FOOD & DRUG #46	520 E BASELINE ROAD	PHOENIX	AZ	85040	10/01/2016
CH093070	SMITHS FOOD & DRUG CENTERS	FRY'S PHARMACY #002	3036 E THOMAS RD	PHOENIX	AZ	85016	10/01/2016
CH093070	SMITHS FOOD & DRUG CENTERS	DBA FRYS FOOD & DRUG #43	2700 W BASELINE	TEMPE	AZ	85283	10/01/2016
CH093070	SMITHS FOOD & DRUG CENTERS	DBA FRY'S FOOD & DRUG #610	4230 W. MCDOWELL ROAD	PHOENIX	AZ	85009	10/01/2019
CH093070	SMITHS FOOD AND DRUG CENTERS	DBA FRYS FOOD & DRUG #81	2250 E BASELINE RD	PHOENIX	AZ	85040	10/01/2016
CH09307D	SMITHS FOOD AND DRUG CENTERS	DBA FRYS FOOD & DRUG #81	2250 E BASELINE RD	PHOENIX	AZ	85040	07/01/2024
CH093070	THOMAS PHOENIX CVS, L.L.C.	DBA: CVS/PHARMACY # 03625	8245 W. THOMAS RD.	PHOENIX	AZ	85033	10/01/2020
CH093070	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/01/2020
CH093070	WAL-MART PHARMACY 10-1549	2020 N 75TH AVE SUITE 1		PHOENIX	AZ	85035	10/01/2016
CH093070	WAL-MART PHARMACY 10-2515	3721 EAST THOMAS ROAD		PHOENIX (EAST)	AZ	85018	10/01/2016
CH093070	WAL-MART PHARMACY 10-3771	6150 SOUTH 35TH AVE		PHOENIX	AZ	85041	10/01/2016
CH09307G	WAL-MART PHARMACY 10-3771	6150 SOUTH 35TH AVE		PHOENIX	AZ	85041	07/01/2024
CH093070	WAL-MART PHARMACY 10-4293	2435 EAST BASELINE ROAD		PHOENIX	AZ	85042	10/01/2016
CH09307S	WAL-MART PHARMACY 10-4293	2435 EAST BASELINE ROAD		PHOENIX	AZ	85042	07/01/2024
CH093070	WAL-MART PHARMACY 10-5189	5250 WEST INDIAN SCHOOL RD		PHOENIX (MARYVALE)	AZ	85031	10/01/2016
CH09307N	WAL-MART PHARMACY 10-5189	5250 WEST INDIAN SCHOOL RD		PHOENIX (MARYVALE)	AZ	85031	07/01/2024
CH093070	WAL-MART PHARMACY 10-5331	7575 WEST LOWER BUCKEYE ROAD		PHOENIX	AZ	85043	10/01/2016
CH093070	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/01/2020
CH093070	WALGREEN ARIZONA DRUG CO	DBA: WALGREENS #10111	3434 W. SOUTHERN AVE	PHOENIX	AZ	85041	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 01197	1745 E SOUTHERN AVE	TEMPE	AZ	85282-7625	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 01272	5101 WEST INDIAN SCHOOL	PHOENIX	AZ	85031	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 01969	6006 N 67TH AVE	GLENDALE	AZ	85301	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 02243	387 N ESTRELLA PKWY	GOODYEAR	AZ	85338	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 02398	925 WEST BASELINE SUITE 108	TEMPE	AZ	85283	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03163	3420 N. SCOTTSDALE RD	SCOTTSDALE	AZ	85251	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03464	3402 N CENTRAL AVE	PHOENIX	AZ	85012	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03789	3605 E THOMAS RD	PHOENIX	AZ	85018	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 04138	7939 E MCDOWELL RD.	SCOTTSDALE	AZ	85257	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 04422	3945 E SOUTHERN AVE	PHOENIX	AZ	85040	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 04909	2921 N. 83RD AVE.	PHOENIX	AZ	85033	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05505	3502 W CAMELBACK RD	PHOENIX	AZ	85019	06/11/2012	09/30/2020
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05893	705 EAST MCDOWELL RD	PHOENIX	AZ	85006	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05937	4315 W MCDOWELL RD	PHOENIX	AZ	85035	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06021	1620 N 59TH AVE	PHOENIX	AZ	85035	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06063	1825 W BETHANY HOME RD	PHOENIX	AZ	85015-2512	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06177	1135 N MESA DRIVE	MESA	AZ	85201	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06535	2420 E BASELINE ROAD	PHOENIX	AZ	85042	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06697	7606 S 7TH ST	PHOENIX	AZ	85042	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06784	2024 W MAIN STREET	MESA	AZ	85201-6802	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06872	2930 N 67TH AVE	PHOENIX	AZ	85033	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07375	1840 W SOUTHERN AVE	PHOENIX	AZ	85041-4631	06/11/2012	02/20/2024
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07387	10710 WEST MCDOWELL ROAD	AVONDALE	AZ	85392	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 07663	8280 W LOWER BUCKEYE ROAD	PHOENIX	AZ	85043	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 09179	5115 W BASELINE ROAD	LAVEEN	AZ	85339	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 11182	1130 W. SOUTHERN AVE	MESA	AZ	85210	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 11610	2000 S. MILL AVE.	TEMPE	AZ	85282	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 13870	4875 E ELLIOT RD.	PHOENIX	AZ	85044	06/11/2012
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05776	1451 N DYSART ROAD	AVONDALE	AZ	85323	10/01/2015
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05504	4249 W GLENDALE AVE	PHOENIX	AZ	85051	01/01/2016
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03087	5625 E THOMAS RD	PHOENIX	AZ	85018	07/01/2021
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 05668	8301 W CAMELBACK	PHOENIX	AZ	85037	07/01/2021
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03769	1616 E. THOMAS	PHOENIX	AZ	85016	07/01/2021
CH093070	WALGREEN ARIZONA DRUG CO.	WALGREENS CENTRAL FILL #21372	120 N 83RD AVE STE 200	TOLLESON	AZ	85353	01/01/2022
CH093070	WALGREEN ARIZONA DRUG CO.	WALGREENS SPECIALTY PHARMACY #16431	2302 N. CENTRAL AVE. SUITE 7	PHOENIX	AZ	85004	04/01/2023
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS #12334	1654 N PEBBLE CREEK PKWY	GOODYEAR	AZ	85395	04/01/2023
CH093070	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03657	3361 NORTH LITCHFIELD RD	GOODYEAR	AZ	85395	01/01/2024
CH09307L	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 06697	7606 S 7TH ST	PHOENIX	AZ	85042	07/01/2024
CH09307C	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 03789	3605 E THOMAS RD	PHOENIX	AZ	85018	07/01/2024
CH093070	WALGREEN CO	DBA: WALGREENS	2370 E MAIN STREET	WOODLAND	CA	95776	09/10/2012	09/30/2015
CH093070	WALGREEN CO	DBA: WALGREENS	17500 PERRIS BLVD	MORENO VALLEY	CA	92551-9547	09/10/2012	09/30/2015
CH093070	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	09/10/2012	11/08/2016
CH093070	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	10/01/2024
CH093070	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	10/01/2024
CH093070	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	10/01/2024
CH093070	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	10/01/2023
CH093070	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	7/1/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		4/10/2018 12:00:00 AM	5/30/2018 9:29 AM
Details	State	Update	Termination Request	Active	To Be Terminated	5/30/2018 9:29 AM
Terminations	Termination Date	Update	Termination Request		7/1/2018 12:00:00 AM	5/30/2018 9:29 AM
Terminations	Termination Effective Date	Update	Termination Request		5/25/2018 12:00:00 AM	5/30/2018 9:29 AM
Terminations	Termination Reason	Update	Termination Request		Site closure	5/30/2018 9:29 AM
Addresses	Billing Address	Update	Change Request	Mountain Park Health Center 2702 N 3rd St Suite 4020 Phoenix, AZ 85004	Mountain Park Health Center - Central Office 3003 N. Central Ave Suite 1600 Phoenix, AZ 85012-2908	4/5/2018 11:37 AM
Addresses	Billing Address	Update	Recertification	Mountain Park Health Center 2702 N 3rd St Suite 4020 Phoenix, AZ 85004	Mountain Park Health Center 2702 N 3rd St Suite 4020 Phoenix, AZ 85004	2/13/2018 5:24 PM
Details	Last Recertification Date	Update	Recertification	2/13/2017 12:00:00 AM	2/13/2018 5:24:48 PM	2/13/2018 5:24 PM
Addresses	Shipping Address	Insert	Change Request		Mountain Park Health Center- Maryvale 6601 W. Thomas Rd. Phoenix, AZ 85033	10/20/2017 10:40 AM
Addresses	Shipping Address	Insert	Change Request		Mountain Park Health Center-Baseline 635 E. Baseline Rd. Phoenix, AZ 85042	10/20/2017 10:40 AM
Details	Is Authorizing Official EHB Data	Update	Change Request	False		10/20/2017 10:40 AM
Contacts	Authorizing Official	Update		Swagert, John R. CEO 6023233470	Swagert, John R. CEO Mountain Park Health Center 6023233470	10/2/2017 3:49 PM
Contacts	Signed By	Update		Swagert, John R. CEO 6023233470	Swagert, John R. CEO Mountain Park Health Center 6023233470	10/2/2017 3:49 PM
Contacts	Primary Contact	Update		Soto, Mary Associate Director of Pharmacy 6025863026	Soto, Mary Associate Director of Pharmacy Mountain Park Health Center 6025863026	9/29/2017 7:13 PM
Contacts	Authorizing Official	Insert			Swagert, John R. CEO 6023233470	7/26/2017 11:59 AM
Contacts	Signed By	Insert			Swagert, John R. CEO 6023233470	7/26/2017 11:59 AM
Contacts	Primary Contact	Update		PODWIKA, ALANA Pharmacy Director 6023233415	Soto, Mary Associate Director of Pharmacy 6025863026	7/26/2017 11:59 AM
Addresses	Main Address	Insert			17624 N. 31st Avenue Phoenix, AZ 85053	7/17/2017 6:47 PM
Addresses	Billing Address	Insert			Mountain Park Health Center 2702 N 3rd St Suite 4020 Phoenix, AZ 85004	7/17/2017 6:47 PM
Contacts	Primary Contact	Insert			PODWIKA, ALANA Pharmacy Director 6023233415	6/29/2017 4:30 PM
Details	Last Recertification Date	Update		2/17/2016 12:00:00 AM	2/13/2017 12:00:00 AM	2/13/2017 1:25 PM
Medicaid Billing	NPI: Number	Insert			1467630012	2/17/2016 6:58 PM
Medicaid Billing	NPI: Number	Insert			1578741120	2/17/2016 6:58 PM
Details	Last Recertification Date	Update			2/17/2016 12:00:00 AM	2/17/2016 6:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	12/18/2015 4:49 PM
Medicaid Billing	Medicaid: Number	Insert			074984	12/18/2015 4:49 PM
Medicaid Billing	Medicaid: State	Insert			AZ	12/18/2015 4:49 PM
Medicaid Billing	NPI: Number	Insert			1386027852	12/18/2015 4:49 PM
Dates	Participating Approval Date	Update			10/16/2015 12:00:00 AM	10/16/2015 2:29 PM
Details	State	Update		Pending	Active	10/16/2015 2:29 PM
Dates	Start Date	Update			1/1/2016 12:00:00 AM	10/16/2015 2:29 PM
Details	340B ID	Update		ONLINE_REG_54762	CH09307H	10/16/2015 1:59 PM
Details	340B ID	Update		ONLINE_REG	ONLINE_REG_54762	10/8/2015 12:55 PM
Details	Last Recertification Date	Insert				10/8/2015 12:55 PM
Details	Grant Number	Insert			H80CS00141	10/8/2015 12:55 PM
Details	340B ID	Insert			ONLINE_REG	10/8/2015 12:55 PM
Details	Is Authorizing Official EHB Data	Insert			False	10/8/2015 12:55 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/8/2015 12:55 PM
Details	Medicare Provider Number	Insert				10/8/2015 12:55 PM
Details	Entity Name	Insert			MOUNTAIN PARK HEALTH CENTER	10/8/2015 12:55 PM
Details	Program Code	Insert			CH	10/8/2015 12:55 PM
Details	Entity Subname	Insert			Mountain Park Health Center - Sunrise	10/8/2015 12:55 PM
Dates	Participating Approval Date	Insert				10/8/2015 12:55 PM
Details	State	Insert			Pending	10/8/2015 12:55 PM
Dates	Registration Date	Insert			10/8/2015 12:00:00 AM	10/8/2015 12:55 PM
Dates	Signed By Date	Insert			10/8/2015 12:00:00 AM	10/8/2015 12:55 PM
Dates	Start Date	Insert				10/8/2015 12:55 PM
Terminations	Termination Comments	Insert				10/8/2015 12:55 PM
Terminations	Termination Date	Insert				10/8/2015 12:55 PM
Terminations	Termination Effective Date	Insert				10/8/2015 12:55 PM
Terminations	Termination Reason	Insert				10/8/2015 12:55 PM

340B Drug Pricing Program Database