Covered Entity Details

CH09130M Canyonlands Community Health Care (Terminated) - information as of 4/29/2025 1:41:34 AM

Main Details

Name

Canyonlands Community Health Care

Subdivision Name

Canyonlands Healthcare - Globe Integrated

Type

HRSA-Funded Health Center

Site ID

BPS-H80-019547

340B ID

CH09130M

Grant Number

H80CS00448

Additional Details

Current Program Status

Terminated

Registration Date

4/3/2018

Participating Start Date

7/1/2018

Participating Approval Date

4/10/2018

Last Recertification Date

2/5/2019

Termination Date
Termination Reason

10/1/2019
Site closure

Contacts

Authorizing Official

Canyonlands Community Health Care
Christopher Hansen, CEO
(928) 645-6600

Primary Contact

Canyonlands Healthcare
Andrew J Lewandowski, Director of Pharmacy
(928) 645-9675 Ext: 2205

Addresses

Street Address

111 West Blake Street
Globe, AZ 85501

Billing Address
Same as Street Address

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	312062
		1891169561

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.

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH091300	Active	BPS-H80-004454	CANYONLANDS COMMUNITY HEALTH CARE	Canyonlands Healthcare - Lake Powell	467 VISTA AVENUE	PAGE	AZ
CH09130A	Terminated	BPS-H80-002011	CANYONLANDS COMMUNITY HEALTH CARE	KAIBETO BOARDING SCHOOL CLINIC	RT 98 DORM STE 4	KAIBETO	AZ
CH09130B	Active	BPS-H80-011483	CANYONLANDS COMMUNITY HEALTH CARE	Canyonlands Healthcare - Chilchinbeto	Chilchinbeto Chapter House Complex	Chilchinbeto	AZ
CH09130D	Active	BPS-H80-009239	CANYONLANDS COMMUNITY HEALTH CARE	Canyonlands Healthcare - Beaver Dam	3272 E RIO VIRGIN RD	LITTLEFIELD	AZ
CH09130G	Active	BPS-H80-010891	CANYONLANDS COMMUNITY HEALTH CARE	Canyonlands Healthcare - Safford	2016 W 16th St	Safford	AZ
CH09130H	Active	BPS-H80-007424	CANYONLANDS COMMUNITY HEALTH CARE	Canyonlands Healthcare - Clifton	10-A S. WARD CANYON ROAD	CLIFTON	AZ
CH09130I	Active	BPS-H80-001987	CANYONLANDS COMMUNITY HEALTH CARE	Canyonlands Healthcare - Duncan	227 Main St	Duncan	AZ
CH09130J	Active	BPS-H80-003516	CANYONLANDS COMMUNITY HEALTH CARE	Canyonlands Healthcare - Urgent Care	440 NORTH NAVAJO	PAGE	AZ
CH09130K	Active	BPS-H80-011479	CANYONLANDS COMMUNITY HEALTH CARE	Canyonlands Healthcare - Globe	5860 S. Hospital Dr., Suite 102	Globe	AZ
CH09130L	Active	BPS-H80-019571	Canyonlands Community Health Care	Canyonlands Healthcare - Safford Integrated	1615 South 1st Avenue	Safford	AZ
CH09130M	Terminated	BPS-H80-019547	Canyonlands Community Health Care	Canyonlands Healthcare - Globe Integrated	111 West Blake Street	Globe	AZ
CH09130N	Active	BPS-H80-032623	Canyonlands Community Health Care	Canyonlands Healthcare - Mobile Clinic	827 Vista Ave.	Page	AZ
CH09130P	Active	BPS-H80-032624	Canyonlands Community Health Care	Canyonlands Healthcare - Mesquite	210 N Sandhill Blvd	Mesquite	NV

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH091300	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	01/01/2025
CH091300	AMAZON PHARMACY #001	4500 S PLEASANT VALLEY RD STE 201		AUSTIN	TX	78744-2911	04/01/2019	01/14/2022
CH091300	AZ PHARMACY, LLC	DBA AMAZON PHARMACY #002	3809 E WATKINS ST	PHOENIX	AZ	85034	04/01/2019	01/14/2022
CH091300	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/01/2022
CH091300	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/01/2022
CH091300	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/01/2022
CH091300	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/01/2022
CH091300	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/01/2022
CH091300	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/01/2022
CH091300	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/01/2022
CH091300	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/01/2022
CH091300	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/01/2022
CH091300	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/01/2022
CH091300	COBRE VALLEY COMMUNITY HOSP	5880 S HOSPITAL DR	OUTPATIENT PHARMACY	GLOBE	AZ	85501-9447	04/01/2016	11/16/2017
CH091300	CORAM ALTERNATE SITE SERVICES, INC	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	12310 WORLD TRADE DRIVE SUITE 100	SAN DIEGO	CA	92128	04/01/2025
CH091300	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	4310 EAST COTTON CENTER BLVD SUITE 110	PHOENIX	AZ	85040-8857	01/01/2025
CH091300	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	2345 WATERS DRIVE	MENDOTA HEIGHTS	MN	55120	04/01/2025
CH091300	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	07/01/2022
CH091300	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	07/01/2022
CH091300	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/01/2022
CH091300	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	10/01/2022
CH091300	DSW ENTERPRISES INC	DBA WALTON DRUG	1520 W THATCHER BLVD	SAFFORD	AZ	85546-3309	10/01/2022
CH091300	GERMAN DOBSON CVS, L.L.C.	DBA CVS/PHARMACY #11144	100 NORTH BROAD ST.	GLOBE	AZ	85501	01/01/2020	04/25/2025
CH091300	M.N. PHARMACY LLC	DBA AMAZON PHARMACY #003	6701 NW 7TH ST., STE. #199	MIAMI	FL	33126	04/01/2019	01/14/2022
CH091300	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	01/01/2022
CH091300	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	10/01/2024
CH091300	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	01/01/2022
CH091300	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	01/01/2022
CH091300	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	01/01/2022
CH091300	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	01/01/2022
CH091300	OPTUMRX	2858 LOKER AVE E STE 100		CARLSBAD	CA	92010-6608	01/01/2022	05/27/2022
CH091300	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	01/01/2022
CH091300	PILLPACK LLC	DBA PILLPACK BY AMAZON PHARMACY	250 COMMERCIAL ST STE 2012	MANCHESTER	NH	03101	04/01/2019	01/14/2022
CH091300	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/01/2022
CH091300	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/01/2022
CH091300	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	07/01/2022
CH091300	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/01/2022
CH091300	SAFEWAY INC	SAFEWAY PHARMACY #0249	P.O.BOX 1346 650 ELM STREET	PAGE	AZ	86040	01/13/2011
CH091300	SAFEWAY INC	SAFEWAY PHARMACY #2648	2125 N HIGHWAY 70	THATCHER	AZ	85552	01/01/2015
CH09130J	SAFEWAY INC	SAFEWAY PHARMACY #0249	P.O.BOX 1346 650 ELM STREET	PAGE	AZ	86040	07/02/2010
CH09130G	SAFEWAY INC	SAFEWAY PHARMACY #2648	2125 N HIGHWAY 70	THATCHER	AZ	85552	07/21/2010
CH091300	SMITH FOOD & DRUG CENTERS INC. DBA SMITH'S PHARMACY #342	350 N SANDHILL BLVD		MESQUITE	NV	89027	01/01/2015
CH09130D	SMITH FOOD & DRUG CENTERS INC. DBA SMITH'S PHARMACY #342	350 N SANDHILL BLVD		MESQUITE	NV	89027	07/12/2010
CH091300	SMITH'S FOOD AND DRUG CTR INC	DBA FRY'S FOOD AND DRUG #109	2115 U.S. HWY 60 STE 200	MIAMI	AZ	85539	01/01/2020
CH091300	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/01/2018
CH091300	WAL-MART PHARMACY 10-1149	755 SO 20TH AVE		SAFFORD	AZ	85546	01/01/2018	11/02/2017
CH091300	WAL-MART PHARMACY 10-1149	755 SO 20TH AVE		SAFFORD	AZ	85546	01/01/2018
CH091300	WAL-MART PHARMACY 10-1334	100 SOUTH RAGUS ROAD		CLAYPOOL	AZ	85532	01/01/2018	11/02/2017
CH091300	WAL-MART PHARMACY 10-1334	100 SOUTH RAGUS ROAD		CLAYPOOL	AZ	85532	01/01/2018
CH091300	WAL-MART PHARMACY 10-1442	1017 WEST HAUL ROAD		PAGE	AZ	86040	01/01/2018	11/02/2017
CH091300	WAL-MART PHARMACY 10-1442	1017 WEST HAUL ROAD		PAGE	AZ	86040	01/01/2018
CH091300	WAL-MART PHARMACY 10-3847	1120 WEST PIONEER BLVD		MESQUITE	NV	89027	01/01/2018	11/02/2017
CH091300	WAL-MART PHARMACY 10-3847	1120 WEST PIONEER BLVD		MESQUITE	NV	89027	01/01/2018
CH091300	WAL-MART PHARMACY 10-5315	2354 COMMERCE PARK DR.		ORLANDO	FL	32819	01/01/2018	11/02/2017
CH091300	WAL-MART PHARMACY 10-5315	2354 COMMERCE PARK DR.		ORLANDO	FL	32819	01/01/2018	03/22/2022
CH091300	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/01/2018
CH091300	WALGREEN ARIZONA DRUG CO.	DBA: WALGREENS # 02429	1995 W THATCHER BLVD	SAFFORD	AZ	85546-3316	04/01/2014
CH091300	WALGREEN ARIZONA DRUG CO.	WALGREENS CENTRAL FILL #21372	120 N 83RD AVE STE 200	TOLLESON	AZ	85353	10/01/2021
CH091300	WALGREEN CO.	DBA: WALGREENS #12646	329 N. SANDHILL BLVD	MESQUITE	NV	89027-4729	04/01/2014
CH091300	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	04/01/2014	08/17/2015
CH091300	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	10/01/2022
CH091300	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	10/01/2022
CH091300	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	10/01/2022
CH091300	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/01/2023
CH091300	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	07/01/2024
CH091300	WALTON DRUG OF MORENCI	WALTON DRUG	408 BURRO ALLEY	MORENCI	AZ	85540	10/01/2022
CH091300	WESTERN PHARMACY GROUP LLC	DBA COMMUNITY MEDICAL CENTER PHARMACY	610 GATEWAY CENTER WAY SUITES A--E	SAN DIEGO	CA	92102	04/01/2019	01/14/2022

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2019 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		7/1/2019 12:00:00 AM	8/7/2019 1:18 PM
Details	State	Update	Termination Request	Active	To Be Terminated	8/7/2019 1:18 PM
Terminations	Termination Date	Update	Termination Request		10/1/2019 12:00:00 AM	8/7/2019 1:18 PM
Terminations	Termination Effective Date	Update	Termination Request		8/1/2019 12:00:00 AM	8/7/2019 1:18 PM
Terminations	Termination Reason	Update	Termination Request		Site closure	8/7/2019 1:18 PM
Details	Last Recertification Date	Update	Recertification		2/5/2019 12:32:43 PM	2/5/2019 12:32 PM
Details	State	Update		Approved	Active	7/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		Hansen, Christopher CEO Canyonlands Community Health Care 9286456600	4/10/2018 12:50 PM
Details	340B ID	Update	New Registration		CH09130M	4/10/2018 12:50 PM
Dates	Participating Approval Date	Update	New Registration		4/10/2018 12:50:47 PM	4/10/2018 12:50 PM
Details	State	Update	New Registration	Pending	Approved	4/10/2018 12:50 PM
Dates	Signed By Date	Update	New Registration		4/9/2018 1:46:04 PM	4/10/2018 12:50 PM
Dates	Start Date	Update	New Registration		7/1/2018 12:00:00 AM	4/10/2018 12:50 PM
Addresses	Main Address	Insert	New Registration		111 West Blake Street Globe, AZ 85501	4/3/2018 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2018 3:01 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		312062	4/3/2018 3:01 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	4/3/2018 3:01 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891169561	4/3/2018 3:01 PM
Contacts	Primary Contact	Insert	New Registration		Lewandowski, Andrew J Director of Pharmacy Canyonlands Healthcare 9286459675-2205	4/3/2018 3:01 PM
Contacts	Authorizing Official	Insert	New Registration		Hansen, Christopher CEO Canyonlands Community Health Care 9286456600	4/3/2018 3:01 PM
Details	Last Recertification Date	Insert	New Registration			4/3/2018 3:01 PM
Details	Grant Number	Insert	New Registration		H80CS00448	4/3/2018 3:01 PM
Details	340B ID	Insert	New Registration			4/3/2018 3:01 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/3/2018 3:01 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/3/2018 3:01 PM
Details	Medicare Provider Number	Insert	New Registration			4/3/2018 3:01 PM
Details	Entity Name	Insert	New Registration		Canyonlands Community Health Care	4/3/2018 3:01 PM
Details	Program Code	Insert	New Registration		CH	4/3/2018 3:01 PM
Details	Entity Subname	Insert	New Registration		Canyonlands Healthcare - Globe Integrated	4/3/2018 3:01 PM
Dates	Participating Approval Date	Insert	New Registration			4/3/2018 3:01 PM
Details	State	Insert	New Registration		Pending	4/3/2018 3:01 PM
Dates	Registration Date	Insert	New Registration		4/3/2018 3:01:05 PM	4/3/2018 3:01 PM
Dates	Signed By Date	Insert	New Registration			4/3/2018 3:01 PM
Dates	Start Date	Insert	New Registration			4/3/2018 3:01 PM
Terminations	Termination Comments	Insert	New Registration			4/3/2018 3:01 PM
Terminations	Termination Date	Insert	New Registration			4/3/2018 3:01 PM
Terminations	Termination Effective Date	Insert	New Registration			4/3/2018 3:01 PM
Terminations	Termination Reason	Insert	New Registration			4/3/2018 3:01 PM

340B Drug Pricing Program Database