Covered Entity Details

RRC030092-03 DEER VALLEY MEDICAL CENTER (Terminated) - information as of 5/10/2025 11:15:00 PM

Main Details

Name

DEER VALLEY MEDICAL CENTER

Subdivision Name

OR Outpatient Surgery

Type

Rural Referral Center

Rural

Yes

340B ID

RRC030092-03

Medicare Provider Number

030092

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

7/16/2017

Participating Start Date

10/1/2017

Participating Approval Date

7/19/2017

Last Recertification Date

9/13/2019

Termination Date
Termination Reason

7/1/2020
For-Profit conversion

Contacts

Authorizing Official

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

Primary Contact

HonorHealth
Kristjon Lindgren, 340B Program Director
(602) 793-5509

Addresses

Street Address

19646 N 27th Ave MOB III #101
Phoenix, AZ 85027

Billing Address

DEER VALLEY MEDICAL CENTER
19829 N 27th Ave
Phoenix, AZ 85027

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
AR	216277105
CO	860181654
CT	008041908
FL	914327100
GA	003105084A
ID	1528169125
IL	860181654005
MT	1528169125
NC	1528169125
OR	000375
VT	0030092
WA	2047108
IA	0218708
ME	1528169125
MI	1528169125
ND	1461023
NV	1528169125
AZ	022214
		1528169125

Shipping Addresses

Shipping Address 1

DEER VALLEY MEDICAL CENTER
19829 N 27th Ave
Phoenix, AZ 85027

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
RRC030092-01	Child	RRC	HONORHEALTH DEER VALLEY MED CENTER	RAD OP MRI-Sonoran	33423 N 32nd Ave	Phoenix	AZ	Terminated
RRC030092-02	Child	RRC	HONORHEALTH DEER VALLEY MED CENTER	RAD OP CT-Sonoran	33423 N 32nd Ave	Phoenix	AZ	Terminated
RRC030092-03	Child	RRC	DEER VALLEY MEDICAL CENTER	OR Outpatient Surgery	19646 N 27th Ave MOB III #101	Phoenix	AZ	Terminated
RRC030092-04	Child	RRC	DEER VALLEY MEDICAL CENTER	Endoscopy OP	19646 N 27th Ave MOB III #204	Phoenix	AZ	Terminated
RRC030092-05	Child	RRC	HONORHEALTH DEER VALLEY MED CENTER	Breast Health Research Center-Sonoran	33423 N 32nd Ave	Phoenix	AZ	Terminated
RRC030092-06	Child	RRC	HONORHEALTH DEER VALLEY MED CENTER	Emergency Department-Sonoran	33423 N 32nd Ave	Phoenix	AZ	Terminated
RRC030092-07	Child	RRC	HONORHEALTH DEER VALLEY MED CENTER	RAD OP General-Sonoran	33423 N 32nd Ave	Phoenix	AZ	Terminated
RRC030092-08	Child	RRC	HONORHEALTH DEER VALLEY MED CENTER	Breast Health Research Center	19646 N 27th Ave #205	Phoenix	AZ	Terminated
RRC030092-09	Child	RRC	DEER VALLEY MEDICAL CENTER	OR Outpatient Surgery	19646 N 27th Ave MOB III #101	Phoenix	AZ	Terminated
RRC030092-10	Child	RRC	HONORHEALTH DEER VALLEY MED CTR	Wound Care OP	19636 N 27th Ave #201	Phoenix	AZ	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Lindgren, Kristjon 340B Program Manager HonorHealth 6027935509	Lindgren, Kristjon 340B Program Director HonorHealth 6027935509	9/10/2022 7:07 PM
Contacts	Primary Contact	Update	Profile Change Request	Lindgren, Kristjon 340B Program Manager HonorHealth 6028706060-331353	Lindgren, Kristjon 340B Program Manager HonorHealth 6027935509	8/18/2020 10:18 PM
Details	State	Update		To Be Terminated	Terminated	7/1/2020 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		5/29/2020 12:00:00 AM	6/1/2020 8:50 AM
Details	State	Update	Termination Request	Active	To Be Terminated	6/1/2020 8:50 AM
Terminations	Termination Comments	Update	Termination Request		JV, no longer HOPD	6/1/2020 8:50 AM
Terminations	Termination Date	Update	Termination Request		7/1/2020 12:00:00 AM	6/1/2020 8:50 AM
Terminations	Termination Effective Date	Update	Termination Request		5/29/2020 12:00:00 AM	6/1/2020 8:50 AM
Terminations	Termination Reason	Update	Termination Request		For-Profit conversion	6/1/2020 8:50 AM
Details	Entity Subname	Update	Change Request	Diagnostic Care Unit	OR Outpatient Surgery	11/15/2019 1:40 PM
Addresses	Main Address	Update	Recertification	19646 N 27th Ave #101 Phoenix, AZ 85027	19646 N 27th Ave MOB III #101 Phoenix, AZ 85027	9/13/2019 12:40 PM
Medicaid Billing	Medicaid: Number	Update	Recertification	218708	0218708	9/13/2019 12:40 PM
Details	Last Recertification Date	Update	Recertification	8/21/2018 2:39:58 PM	9/13/2019 12:40:04 PM	9/13/2019 12:40 PM
Details	Entity Subname	Update	Recertification	OR Outpatient Surgery	Diagnostic Care Unit	9/13/2019 12:40 PM
Contacts	Authorizing Official	Update	AO Change Request	Post, Kim EVP Chief Operations Officer HonorHealth 4805875087	Baker, Gary SVP-CEO-HOSPITAL HonorHealth 4805830803	8/22/2019 12:17 PM
Contacts	Primary Contact	Update	Change Request	Lindgren, Kristjon 340B Program Manager HonorHealth 6028706060-331353	Lindgren, Kristjon 340B Program Manager HonorHealth 6028706060-331353	8/2/2019 10:39 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 12:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2019 11:24 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		218708	6/14/2019 11:24 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	6/14/2019 11:24 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2019 11:24 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1528169125	6/14/2019 11:24 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		ME	6/14/2019 11:24 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2019 11:24 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1528169125	6/14/2019 11:24 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	6/14/2019 11:24 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2019 11:24 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1461023	6/14/2019 11:24 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		ND	6/14/2019 11:24 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2019 11:24 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1528169125	6/14/2019 11:24 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NV	6/14/2019 11:24 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
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		216277105	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		860181654	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		008041908	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		914327100	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003105084A	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1528169125	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		860181654005	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1528169125	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MT	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1528169125	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000375	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0030092	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		VT	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2047108	12/17/2018 11:58 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	12/17/2018 11:58 AM
Details	Last Recertification Date	Update	Recertification	11/29/2017 10:00:16 PM	8/21/2018 2:39:58 PM	8/21/2018 2:39 PM
Contacts	Authorizing Official	Update	Change Request	Moravec, Susan AVP, Chief of Phamacy HonorHealth 4808825941	Pope, Alice Chief Financial Officer HonorHealth 4808825544	2/20/2018 10:46 AM
Addresses	Shipping Address	Insert	Recertification		DEER VALLEY MEDICAL CENTER 19829 N 27th Ave Phoenix, AZ 85027	11/29/2017 10:00 PM
Addresses	Main Address	Update	Recertification	19647 N. 27th Avenue Suite 101 Phoenix, AZ 85027	19646 N 27th Ave #101 Phoenix, AZ 85027	11/29/2017 10:00 PM
Addresses	Billing Address	Update	Recertification	DEER VALLEY MEDICAL CENTER 19829 N. 27th Avenue Phoenix, AZ 85027	DEER VALLEY MEDICAL CENTER 19829 N 27th Ave Phoenix, AZ 85027	11/29/2017 10:00 PM
Details	Last Recertification Date	Update	Recertification		11/29/2017 10:00:16 PM	11/29/2017 10:00 PM
Details	Entity Subname	Update	Recertification	Outpatient Surgery Center	OR Outpatient Surgery	11/29/2017 10:00 PM
Contacts	Primary Contact	Update	Change Request	Moravec, Susan AVP, Chief of Phamacy 4808825941	Lindgren, Kristjon 340B Program Supervisor HonorHealth 6028706060-331353	10/13/2017 2:20 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	Signed By	Update		Moravec, Susan AVP, Chief of Phamacy 4808825941	Moravec, Susan AVP, Chief of Phamacy HonorHealth 4808825941	10/3/2017 3:04 PM
Addresses	Shipping Address	Delete		DEER VALLEY MEDICAL CENTER 19829 N. 27th Avenue Phoenix, AZ 85027		8/14/2017 6:22 PM
Addresses	Main Address	Insert			19647 N. 27th Avenue Suite 101 Phoenix, AZ 85027	8/14/2017 6:22 PM
Addresses	Billing Address	Insert			DEER VALLEY MEDICAL CENTER 19829 N. 27th Avenue Phoenix, AZ 85027	8/14/2017 6:22 PM
Addresses	Shipping Address	Insert			DEER VALLEY MEDICAL CENTER 19829 N. 27th Avenue Phoenix, AZ 85027	8/14/2017 6:22 PM
Contacts	Authorizing Official	Insert			Moravec, Susan AVP, Chief of Phamacy 4808825941	8/14/2017 6:22 PM
Contacts	Primary Contact	Update		Lindgren, Kristjon 340B Program Supervisor 6028706060-330172	Moravec, Susan AVP, Chief of Phamacy 4808825941	8/14/2017 6:22 PM
Contacts	Signed By	Insert			Moravec, Susan AVP, Chief of Phamacy 4808825941	8/14/2017 6:22 PM
Details	State	Update		Approved	Active	8/14/2017 6:22 PM
Contacts	Primary Contact	Insert			Lindgren, Kristjon 340B Program Supervisor 6028706060-330172	7/26/2017 2:04 PM
Dates	Participating Approval Date	Update			7/19/2017 12:00:00 AM	7/19/2017 7:11 PM
Details	State	Update		Pending	Approved	7/19/2017 7:11 PM
Dates	Start Date	Update			10/1/2017 12:00:00 AM	7/19/2017 7:11 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_78899	RRC030092-03	7/18/2017 9:09 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_78899	7/16/2017 5:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/16/2017 5:10 PM
Medicaid Billing	Medicaid: Number	Insert			022214	7/16/2017 5:10 PM
Medicaid Billing	Medicaid: State	Insert			AZ	7/16/2017 5:10 PM
Medicaid Billing	NPI: Number	Insert			1528169125	7/16/2017 5:10 PM
Details	Last Recertification Date	Insert				7/16/2017 5:10 PM
Details	Grant Number	Insert				7/16/2017 5:10 PM
Details	340B ID	Insert				7/16/2017 5:10 PM
Details	Is Authorizing Official EHB Data	Insert				7/16/2017 5:10 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/16/2017 5:10 PM
Details	Medicare Provider Number	Insert			030092	7/16/2017 5:10 PM
Details	Entity Name	Insert			DEER VALLEY MEDICAL CENTER	7/16/2017 5:10 PM
Details	Program Code	Insert			RRC	7/16/2017 5:10 PM
Details	Entity Subname	Insert			Outpatient Surgery Center	7/16/2017 5:10 PM
Dates	Participating Approval Date	Insert				7/16/2017 5:10 PM
Details	State	Insert			Pending	7/16/2017 5:10 PM
Dates	Registration Date	Insert			7/16/2017 12:00:00 AM	7/16/2017 5:10 PM
Dates	Signed By Date	Insert			7/16/2017 12:00:00 AM	7/16/2017 5:10 PM
Dates	Start Date	Insert				7/16/2017 5:10 PM
Terminations	Termination Comments	Insert				7/16/2017 5:10 PM
Terminations	Termination Date	Insert				7/16/2017 5:10 PM
Terminations	Termination Effective Date	Insert				7/16/2017 5:10 PM
Terminations	Termination Reason	Insert				7/16/2017 5:10 PM