| Contacts | Authorizing Official | Update | Profile Change Request | Ziemer, Cody W
Chief Financial Officer
Banner Gateway Medical Center
4805432277 | Ziemer, Cody W
Chief Financial Officer
Banner University Medical Center Phoenix
6028398507 | 4/3/2025 6:52 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Ziemer, Cody W
Chief Financial Officer
Banner Gateway Medical Center
4805432945 | Ziemer, Cody W
Chief Financial Officer
Banner Gateway Medical Center
4805432277 | 12/15/2020 10:10 AM |
| Contacts | Authorizing Official | Update | Change Request | Huff, Matthew P
CFO
Banner Health
4805432277 | Ziemer, Cody W
Chief Financial Officer
Banner Gateway Medical Center
4805432945 | 2/24/2020 7:31 AM |
| Contacts | Authorizing Official | Update | Change Request | Yoder, Lamont M
CEO
Banner Gateway Medical Center
4805432100 | Huff, Matthew P
CFO
Banner Health
4805432277 | 12/12/2017 3:46 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Yoder, Lamont
CEO
Banner Gateway Medical Center
4805432868 | Yoder, Lamont M
CEO
Banner Gateway Medical Center
4805432100 | 10/30/2017 3:42 PM |
| Contacts | Authorizing Official | Update | | Yoder, Lamont
CEO
4805432868 | Yoder, Lamont
CEO
Banner Gateway Medical Center
4805432868 | 10/2/2017 2:48 PM |
| Contacts | Primary Contact | Update | | Nacy, Tanya
Pharmacy Director
4805432190 | Nacy, Tanya
Pharmacy Director
Banner Gateway Medical Center
4805432190 | 9/26/2017 1:12 PM |
| Contacts | Authorizing Official | Update | | Shepardson, Dean
CFO
4805432277 | Yoder, Lamont
CEO
4805432868 | 9/11/2017 3:29 PM |
| Contacts | Signed By | Insert | | | Flake, Leslie
Chief Financial Officer
6027473950 | 7/26/2017 12:28 PM |
| Contacts | Primary Contact | Insert | | | Nacy, Tanya
Pharmacy Director
4805432190 | 7/26/2017 12:28 PM |
| Contacts | Authorizing Official | Update | | Matenaer, Thomas M.
Chief Financial Officer
4805432295 | Shepardson, Dean
CFO
4805432277 | 7/17/2017 8:26 PM |
| Addresses | Main Address | Insert | | |
1920 North Higley Road, Suite 306
Gilbert, AZ 85234 | 4/25/2017 11:42 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | | | 1/8/2016 12:00:00 AM | 4/25/2017 11:42 AM |
| Details | State | Update | | Active | Terminated | 4/25/2017 11:42 AM |
| Terminations | Termination Comments | Update | | | This site has been a child site for the Banner Gateway Medical Center Covered Entity (DSH030122). Upon annual evaluation of child site status it was determined that this site was assessed as eligible in error. No medications have been purchased at 340B prices for this site to date nor have there been contract pharmacy scripts that have qualified with this site as the encounter location. | 4/25/2017 11:42 AM |
| Terminations | Termination Date | Update | | | 7/1/2017 12:00:00 AM | 4/25/2017 11:42 AM |
| Terminations | Termination Effective Date | Update | | | 4/24/2017 12:00:00 AM | 4/25/2017 11:42 AM |
| Terminations | Termination Reason | Update | | | Site closure | 4/25/2017 11:42 AM |
| Contacts | Authorizing Official | Insert | | | Matenaer, Thomas M.
Chief Financial Officer
4805432295 | 12/27/2016 10:19 AM |
| Details | Last Recertification Date | Update | | | 9/7/2016 12:00:00 AM | 9/7/2016 12:16 PM |
| Dates | Participating Approval Date | Update | | | 2/12/2016 12:00:00 AM | 2/12/2016 10:20 AM |
| Details | State | Update | | Pending | Active | 2/12/2016 10:20 AM |
| Dates | Start Date | Update | | | 4/1/2016 12:00:00 AM | 2/12/2016 10:20 AM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_56919 | DSH030122E | 1/26/2016 12:41 PM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_56919 | 1/8/2016 11:52 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 1/8/2016 11:52 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 262489 | 1/8/2016 11:52 AM |
| Medicaid Billing | Medicaid: State | Insert | | | AZ | 1/8/2016 11:52 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1699884858 | 1/8/2016 11:52 AM |
| Details | Last Recertification Date | Insert | | | | 1/8/2016 11:52 AM |
| Details | Grant Number | Insert | | | | 1/8/2016 11:52 AM |
| Details | 340B ID | Insert | | | | 1/8/2016 11:52 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 1/8/2016 11:52 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 1/8/2016 11:52 AM |
| Details | Medicare Provider Number | Insert | | | 030122 | 1/8/2016 11:52 AM |
| Details | Entity Name | Insert | | | BANNER GATEWAY MEDICAL CENTER | 1/8/2016 11:52 AM |
| Details | Program Code | Insert | | | DSH | 1/8/2016 11:52 AM |
| Details | Entity Subname | Insert | | | Banner Gateway Weight Loss Center | 1/8/2016 11:52 AM |
| Dates | Participating Approval Date | Insert | | | | 1/8/2016 11:52 AM |
| Details | State | Insert | | | Pending | 1/8/2016 11:52 AM |
| Dates | Registration Date | Insert | | | 1/8/2016 12:00:00 AM | 1/8/2016 11:52 AM |
| Dates | Signed By Date | Insert | | | 1/8/2016 12:00:00 AM | 1/8/2016 11:52 AM |
| Dates | Start Date | Insert | | | | 1/8/2016 11:52 AM |
| Terminations | Termination Comments | Insert | | | | 1/8/2016 11:52 AM |
| Terminations | Termination Date | Insert | | | | 1/8/2016 11:52 AM |
| Terminations | Termination Effective Date | Insert | | | | 1/8/2016 11:52 AM |
| Terminations | Termination Reason | Insert | | | | 1/8/2016 11:52 AM |