Covered Entity Details

CAH031317-05 La Paz Regional Hospital (Terminated) - information as of 5/5/2025 11:56:08 PM

Main Details

Name

La Paz Regional Hospital

Subdivision Name

PARKER PODIATRY - Podiatry

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH031317-05

Medicare Provider Number

031317

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/10/2018

Participating Start Date

7/1/2018

Participating Approval Date

4/30/2018

Last Recertification Date

8/29/2019

Termination Date
Termination Reason

7/1/2020
Hospital Outpatient facility no longer eligible

Contacts

Authorizing Official

La Paz Regional Hospital
Kevin M Brown, CEO
(928) 669-7300

Primary Contact

La Paz Regional Hospital
Zafer L. Genc, Director of Pharmacy
(928) 669-7452

Addresses

Street Address

1713 Kofa Ave
STE
K
Parker, AZ 85344

Billing Address

La Paz Regional Hospital
1200 Mohave Rd
Parker, AZ 85344

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	480046
WA	405378
ID	1053684555
OR	1053684555
CA	ZZT24646F
		1568875771,1053684555

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
CAH031317-01	Child	CAH	La Paz Regional Hospital	Parker Medical Center	905 Fiesta Ave	Parker	AZ	Terminated
CAH031317-02	Child	CAH	La Paz Regional Hospital	Tri-Valley Medical Center	39726 Harquahala Road	Salome	AZ	Active
CAH031317-03	Child	CAH	La Paz Regional Hospital	La Paz Medical Services	150 E. Tyson Road	Quartzsite	AZ	Active
CAH031317-04	Child	CAH	La Paz Regional Hospital	Bouse Medical Clinic	44031 E. Plumosa Road	Bouse	AZ	Active
CAH031317-05	Child	CAH	La Paz Regional Hospital	PARKER PODIATRY - Podiatry	1713 Kofa Ave	Parker	AZ	Terminated
CAH031317-06	Child	CAH	La Paz Regional Hospital	La Paz Healthcare: Parker Clinic - Family Practice	601 W. Riverside Dr	Parker	AZ	Terminated
CAH031317-07	Child	CAH	La Paz Regional Hospital	La Paz Healthcare: Kofa Clinic	1713 Kofa Ave	Parker	AZ	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	7/1/2020 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		4/1/2014 12:00:00 AM	4/13/2020 12:47 PM
Details	State	Update	Termination Request	Active	To Be Terminated	4/13/2020 12:47 PM
Terminations	Termination Comments	Update	Termination Request		Never had a 340B purchase	4/13/2020 12:47 PM
Terminations	Termination Date	Update	Termination Request		7/1/2020 12:00:00 AM	4/13/2020 12:47 PM
Terminations	Termination Effective Date	Update	Termination Request		4/1/2020 12:00:00 AM	4/13/2020 12:47 PM
Terminations	Termination Reason	Update	Termination Request		Hospital Outpatient facility no longer eligible	4/13/2020 12:47 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2019 5:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		480046	8/29/2019 5:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AZ	8/29/2019 5:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2019 5:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		405378	8/29/2019 5:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WA	8/29/2019 5:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2019 5:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1053684555	8/29/2019 5:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		ID	8/29/2019 5:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2019 5:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1053684555	8/29/2019 5:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		OR	8/29/2019 5:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2019 5:16 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		ZZT24646F	8/29/2019 5:16 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	8/29/2019 5:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1568875771	8/29/2019 5:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1053684555	8/29/2019 5:16 PM
Details	Last Recertification Date	Update	Recertification	9/10/2018 2:58:23 PM	8/29/2019 5:16:28 PM	8/29/2019 5:16 PM
Details	Last Recertification Date	Update	Recertification		9/10/2018 2:58:23 PM	9/10/2018 2:58 PM
Details	State	Update		Approved	Active	7/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		Brown, Kevin M CEO La Paz Regional Hospital 9286697300	4/30/2018 3:43 PM
Details	340B ID	Update	New Registration		CAH031317-05	4/30/2018 3:43 PM
Details	Entity Subname	Update	New Registration	PARKER PODIATRY	PARKER PODIATRY - Podiatry	4/30/2018 3:43 PM
Dates	Participating Approval Date	Update	New Registration		4/30/2018 3:43:58 PM	4/30/2018 3:43 PM
Details	State	Update	New Registration	Pending	Approved	4/30/2018 3:43 PM
Dates	Signed By Date	Update	New Registration		4/24/2018 4:41:20 PM	4/30/2018 3:43 PM
Dates	Start Date	Update	New Registration		7/1/2018 12:00:00 AM	4/30/2018 3:43 PM
Addresses	Main Address	Insert	New Registration		1713 Kofa Ave STE K Parker, AZ 85344	4/10/2018 3:36 PM
Addresses	Billing Address	Insert	New Registration		La Paz Regional Hospital 1200 Mohave Rd Parker, AZ 85344	4/10/2018 3:36 PM
Contacts	Primary Contact	Insert	New Registration		Genc, Zafer L. Director of Pharmacy La Paz Regional Hospital 9286697452	4/10/2018 3:36 PM
Contacts	Authorizing Official	Insert	New Registration		Brown, Kevin M CEO La Paz Regional Hospital 9286697300	4/10/2018 3:36 PM
Details	Last Recertification Date	Insert	New Registration			4/10/2018 3:36 PM
Details	Grant Number	Insert	New Registration			4/10/2018 3:36 PM
Details	340B ID	Insert	New Registration			4/10/2018 3:36 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/10/2018 3:36 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/10/2018 3:36 PM
Details	Medicare Provider Number	Insert	New Registration		031317	4/10/2018 3:36 PM
Details	Entity Name	Insert	New Registration		La Paz Regional Hospital	4/10/2018 3:36 PM
Details	Program Code	Insert	New Registration		CAH	4/10/2018 3:36 PM
Details	Entity Subname	Insert	New Registration		PARKER PODIATRY	4/10/2018 3:36 PM
Dates	Participating Approval Date	Insert	New Registration			4/10/2018 3:36 PM
Details	State	Insert	New Registration		Pending	4/10/2018 3:36 PM
Dates	Registration Date	Insert	New Registration		4/10/2018 3:36:57 PM	4/10/2018 3:36 PM
Dates	Signed By Date	Insert	New Registration			4/10/2018 3:36 PM
Dates	Start Date	Insert	New Registration			4/10/2018 3:36 PM
Terminations	Termination Comments	Insert	New Registration			4/10/2018 3:36 PM
Terminations	Termination Date	Insert	New Registration			4/10/2018 3:36 PM
Terminations	Termination Effective Date	Insert	New Registration			4/10/2018 3:36 PM
Terminations	Termination Reason	Insert	New Registration			4/10/2018 3:36 PM