Covered Entity Details

PED033302-104 PHOENIX CHILDREN'S HOSPITAL (Terminated) - information as of 5/1/2025 11:42:40 PM

Main Details

Name

PHOENIX CHILDREN'S HOSPITAL

Subdivision Name

Phoenix Children's Pediatrics

Type

Children's Hospital

Rural

340B ID

PED033302-104

Medicare Provider Number

033302

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/11/2019

Participating Start Date

1/1/2020

Participating Approval Date

11/15/2019

Last Recertification Date

9/8/2021

Termination Date
Termination Reason

4/1/2022
Business decision by the Covered Entity

Contacts

Authorizing Official

Phoenix Children's Hospital
Kari Cornicelli, Executive Vice President and Chief Financial Officer
(602) 933-5468

Primary Contact

Phoenix Children's Hospital
Syed Jaffery, Director of Pharmacy Business Operations
(602) 933-5185

Addresses

Street Address

1501 N Gilbert Road
Suite 203
Gilbert, AZ 85296

Billing Address
Same as Street Address

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?
No

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
PED033302-01	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s East Valley Surgery Center	5131 East Southern Avenue	Mesa	AZ	Active
PED033302-03	Child	PED	PHOENIX CHILDREN'S HOSPITAL	PHOENIX CHILDREN'S SPECIALTY CARE CENTER SCOTTSDALE - URGENT CARE	6990 E. Shea. Blvd.	SCOTTSDALE	AZ	Terminated
PED033302-06	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Dermatology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-07	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Endocrinology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-08	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Gastroenterology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-09	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Hematology and Oncology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-10	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Nephrology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-100	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Mercy Gilbert - Pulmonology	3420 Mercy Road	Gilbert	AZ	Active
PED033302-101	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Tucson - Dermatology	5983 E. Grant Road	Tucson	AZ	Terminated
PED033302-102	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Pediatrics	1501 N Gilbert Road	Gilbert	AZ	Terminated
PED033302-103	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Plastic Surgery	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-104	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Pediatrics	1501 N Gilbert Road	Gilbert	AZ	Terminated
PED033302-105	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Arrowhead - Neurology	18555 N 79th Avenue	Glendale	AZ	Terminated
PED033302-106	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Arrowhead - Developmental Pediatrics - Developmental Pediatrics	18555 N. 79th Avenue	Glendale	AZ	Terminated
PED033302-107	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Mercy Gilbert - Dermatology	3420 Mercy Road	Gilbert	AZ	Active
PED033302-108	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Mercy Gilbert - Genetics	3420 Mercy Road	Gilbert	AZ	Active
PED033302-109	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Mercy Gilbert - Pain Clinic	3420 Mercy Road	Gilbert	AZ	Active
PED033302-11	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Neurology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-110	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Pediatrics - Cottonwood	800 Cove Parkway	Cottonwood	AZ	Terminated
PED033302-111	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Pediatrics - San Tan Village	1790 E Boston Street	Gilbert	AZ	Terminated
PED033302-112	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Urology	6524 W SACK DR	Glendale	AZ	Active
PED033302-113	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Nephrology	6524 W SACK DR	Glendale	AZ	Active
PED033302-114	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Neurology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-115	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Allergy & Immunology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-116	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Tucson - Cardiology	5983 E Grant Road	Tucson	AZ	Terminated
PED033302-117	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Neuropsychology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-118	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center - Rheumatology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-119	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Endocrinology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-12	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Orthopedics	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-120	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center - Genetics	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-121	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center - Pain Medicine	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-122	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Northwest Valley Specialty Care Center - Neurosurgery	6524 W SACK DR	Glendale	AZ	Active
PED033302-123	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care at St. Joseph's - Plastic Surgery	124 W Thomas Road	Phoenix	AZ	Terminated
PED033302-124	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Cardiology - Casa Grande	1828 E Florence Boulevard, Building C	Casa Grande	AZ	Terminated
PED033302-125	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center - Radiology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-126	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center - Genetics	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-127	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Developmental Pediatrics	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-128	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center - Pediatric Surgery	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-129	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center - Pain Management	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-13	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Psychiatry	3370 Mercy Road	Gilbert	AZ	Active
PED033302-130	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care at St. Joseph's - Neurosurgery	124 W Thomas Road	Phoenix	AZ	Terminated
PED033302-131	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center - Plastic Surgery	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-132	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Pediatric Surgery	6524 W SACK DR	Glendale	AZ	Active
PED033302-133	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Cardiology - Douglas	815 15th Street	Douglas	AZ	Terminated
PED033302-134	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Plastic Surgery	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-135	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Developmental Pediatrics	6524 W SACK DR	Glendale	AZ	Active
PED033302-136	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Genetics	6524 W SACK DR	Glendale	AZ	Active
PED033302-137	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Arrowhead - Neurosurgery	18555 N 79th Avenue	Glendale	AZ	Terminated
PED033302-138	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Scottsdale Specialty Care Center - Plastic Surgery	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-139	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Tucson - Neurosurgery	5983 E Grant Road	Tucson	AZ	Terminated
PED033302-14	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - NeuroPsychology	3370 Mercy Road	Gilbert	AZ	Terminated
PED033302-140	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Scottsdale Specialty Care Center - Developmental Pediatrics	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-141	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Scottsdale Specialty Care Center - Pediatric Surgery	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-142	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Cardiology - Safford	2115 W 16th Street	Safford	AZ	Terminated
PED033302-143	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Plastic Surgery	3370 Mercy Road	Gilbert	AZ	Active
PED033302-144	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Cardiology - Sierra Vista	155 Calle Portal	Sierra Vista	AZ	Terminated
PED033302-145	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Psychology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-146	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Orthopedics	3370 S Mercy Road	Gilbert	AZ	Active
PED033302-147	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Ambulatory - Nephrology	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-148	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Neurosurgery	3370 Mercy Road	Gilbert	AZ	Active
PED033302-149	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Cardiology	3370 S Mercy Road	Gilbert	AZ	Active
PED033302-15	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Pulmonology	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-150	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Pediatric Surgery	3370 Mercy Road	Gilbert	AZ	Active
PED033302-151	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Otolaryngology	3370 Mercy Road	Gilbert	AZ	Terminated
PED033302-152	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Gastroenterology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-153	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Ortho Radiology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-154	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Pediatric & Adolescent Gynecology	3370 Mercy Road	Gilbert	AZ	Active
PED033302-155	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Developmental Pediatrics	3370 Mercy Road	Gilbert	AZ	Active
PED033302-156	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Mesa Pediatrics - Gilbert	2550 E Guadalupe Road	Gilbert	AZ	Terminated
PED033302-157	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Mesa Pediatrics - Chandler	60 S Kyrene Road	Chandler	AZ	Terminated
PED033302-158	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Mesa Pediatrics - Tempe	6301 S McClintock Drive	Tempe	AZ	Terminated
PED033302-159	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Mesa Pediatrics - San Tan	3592 S Atherton Blvd	Gilbert	AZ	Terminated
PED033302-16	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - Radiology and Imaging	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-160	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Behavioral Health	3370 Mercy Road	Gilbert	AZ	Active
PED033302-161	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Scottsdale Specialty Care Center - Psychology	6990 E Shea Blvd	Scottssdale	AZ	Active
PED033302-162	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Southwest Valley Specialty Care Center - Allergy & Immunology	1665 N Avondale Blvd	Avondale	AZ	Active
PED033302-163	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital - Ambulatory Physical Medicine Clinic	1919 E. Thomas Rd	Phoenix	AZ	Active
PED033302-164	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Pulmonology - Pulmonology	3370 S Mercy Road	Gilbert	AZ	Active
PED033302-165	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Southwest Valley - Hand Surgery - Hand Surgery	1665 N Avondale Blvd	Avondale	AZ	Active
PED033302-166	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Southwest Valley - Developmental Pediatrics - Developmental Pediatrics	1665 N Avondale Blvd	Avondale	AZ	Active
PED033302-167	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Southwest Valley - Physical Medicine & Rehabilitation - Physical Medicine & Rehabilitation	1665 N Avondale Blvd	Avondale	AZ	Active
PED033302-168	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Specialty Care Center - GI Surgery - GI Surgery	5131 E Southern Ave	Mesa	AZ	Active
PED033302-169	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Scottsdale Specialty Care Center - GI Surgery - GI Surgery	6990 E Shea Blvd	Scottsdale	AZ	Active
PED033302-17	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s East Valley Specialty Care Center - Rheumatology	5131 E Southern Ave	Mesa	AZ	Active
PED033302-170	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Emergency Department - Avondale Campus - Emergency Department	1665 N Avondale Blvd	Avondale	AZ	Active
PED033302-18	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's East Valley Urgent Care	5131 E Southern Ave	Mesa	AZ	Terminated
PED033302-19	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Endocrinology	6524 W SACK DR	Glendale	AZ	Active
PED033302-20	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Gastroenterology	6524 W SACK DR	Glendale	AZ	Active
PED033302-21	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Neurology	6524 W SACK DR	Glendale	AZ	Active
PED033302-22	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Orthopedics	6524 W SACK DR	Glendale	AZ	Active
PED033302-23	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Specialty Care Center - Pulmonology	6524 W SACK DR	Glendale	AZ	Active
PED033302-24	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Northwest Valley Urgent Care	20325 N 51st Avenue	Glendale	AZ	Terminated
PED033302-25	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Center - Scottsdale Cardiology	6990 E Shea Boulevard	Scottsdale	AZ	Terminated
PED033302-26	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Endocrinology	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-27	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Gastroenterology	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-28	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Scottsdale Specialty Care Center - Nephrology	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-29	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Neurology	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-30	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Orthopedics	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-31	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Pulmonology	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-32	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Urgent Care	6990 E Shea Boulevard	Scottsdale	AZ	Terminated
PED033302-33	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Urology	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-34	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Hospital Ambulatory - General Pediatrics	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-35	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic (Rosenberg Building) PCMG Gynecology	1920 E Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-36	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Clinic - Hematology/Oncology	1919 East Thomas Road	Phoenix	AZ	Terminated
PED033302-37	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Rosenberg Children's Medical Plaza - Nephrology	1920 E Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-38	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Rosenberg - Radiology & Imaging	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-39	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Rosenberg Children's Medical Plaza - Rheumatology	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-40	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Urology	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-41	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Hemodialysis	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-42	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Dermatology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-43	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Endocrinology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-44	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Gastroenterology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-45	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – General Pediatrics	1665 N Avondale Boulevard	Avondale	AZ	Terminated
PED033302-46	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Arrowhead Specialty Care Center – Hematology & Oncology Clinic	6524 W SACK DR	Glendale	AZ	Active
PED033302-47	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Neuropsychology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-48	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Neurology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-49	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Orthopedics	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-50	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Urgent Care	1665 N Avondale Boulevard	Avondale	AZ	Terminated
PED033302-51	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Psychiatry	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-52	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Pulmonology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-53	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Clinic - Neurology	1919 East Thomas Road	Phoenix	AZ	Terminated
PED033302-54	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Hospital Ambulatory - Audiology	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-55	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Hospital Ambulatory - Neurosurgery	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-56	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Hospital Ambulatory - Psychiatry	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-57	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Hospital Ambulatory - Psychology	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-58	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Hospital Ambulatory - Neurology	1919 E Thomas Road	Phoenix	AZ	Active
PED033302-59	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Ambulatory Surgery Center	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-60	Child	PED	PHOENIX CHILDREN'S HOSPITAL	PCMG Radiology	1920 E. Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-61	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Urology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-62	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Southwest Valley Specialty Care Center – Rehabilitation	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-63	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Southwest Valley Specialty Care Center - Nephrology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-64	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg - Infusion Center	1920 E Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-65	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Peritoneal Dialysis	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-66	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Hemodialysis	1920 East Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-67	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Genetics and Metabolism	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-68	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Mercy Gilbert - Diagnostic Radiology	3555 South Val Vista Drive	Gilbert	AZ	Terminated
PED033302-69	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Mercy Gilbert - Respiratory Therapy	3555 South Val Vista Drive	Gilbert	AZ	Terminated
PED033302-70	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s East Valley Specialty Care Center - Neurosurgery	5131 East Southern Avenue	Mesa	AZ	Active
PED033302-71	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Scottsdale Specialty Care Center – Neurosurgery	6990 E Shea Boulevard	Scottsdale	AZ	Active
PED033302-72	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Homeless Youth Outreach – UMOM New Day Center	3333 E Van Buren Street	Phoenix	AZ	Terminated
PED033302-73	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Cardiology - Scottsdale	10250 N 92nd Street	Scottsdale	AZ	Active
PED033302-74	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Homeless Youth Outreach - Crews'n Healthmobile	1919 E Thomas Road	Phoenix	AZ	Terminated
PED033302-75	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Homeless Youth Outreach – Children’s First Leadership Academy	1648 S 16th Street	Phoenix	AZ	Terminated
PED033302-76	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Breathmobile	1919 E Thomas Road	Phoenix	AZ	Terminated
PED033302-77	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Arrowhead - Cardiology	18555 N 79th Avenue	Glendale	AZ	Active
PED033302-78	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Heart Center - East Valley	3420 South Mercy Road	Gilbert	AZ	Terminated
PED033302-79	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care Rosenberg Children's Medical Plaza - Endocrinology	1920 E Cambridge Avenue	Phoenix	AZ	Active
PED033302-80	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Pediatrics - Scottsdale	5425 E Bell Road	Scottsdale	AZ	Terminated
PED033302-81	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s East Valley Specialty Care Center - Infusion Center	5131 E Southern Avenue	Mesa	AZ	Active
PED033302-82	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Arrowhead Specialty Care Center - CCBD and Infusion Center	6524 W SACK DR	Glendale	AZ	Active
PED033302-83	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic (Rosenberg Building) PCMG Allergy & Immunology	1920 E Cambridge Ave	Phoenix	AZ	Terminated
PED033302-84	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Hospital Homeless Youth Outreach - Phoenix Dream Center	3210 NW Grand Avenue	Phoenix	AZ	Terminated
PED033302-85	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Gilbert - Cardiology	1501 N Gilbert Road	Gilbert	AZ	Terminated
PED033302-86	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Southwest Valley Specialty Care Center - Cardiology	1665 N Avondale Boulevard	Avondale	AZ	Active
PED033302-87	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Ophthalmology	3370 S Mercy Road	Glbert	AZ	Terminated
PED033302-88	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Ophthalmology – West Mesa	2045 S Vineyard Drive	Mesa	AZ	Terminated
PED033302-89	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Ophthalmology – Glendale	6320 W Union Hills Drive	Glendale	AZ	Terminated
PED033302-90	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Ophthalmology – Scottsdale	20201 N Scottsdale Healthcare Drive	Scottsdale	AZ	Terminated
PED033302-91	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Arizona Pediatric Eye Specialists - Shea	4530 East Shea Blvd.	Phoenix	AZ	Terminated
PED033302-92	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Rosenberg Children's Medical Plaza - Ophthalmology	1920 E Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-93	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Ophthalmology – West Phoenix	9250 W Thomas Rd	Phoenix	AZ	Terminated
PED033302-94	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Pediatrics – North Phoenix	3805 E Bell Road	Phoenix	AZ	Terminated
PED033302-95	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Pediatrics - Dobson Village	205 S Dobson Road	Chandler	AZ	Terminated
PED033302-96	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Speciality Care ENT/Otolaryngology - Mesa	2045 S Vineyard Drive	Mesa	AZ	Terminated
PED033302-97	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children’s Specialty Care Rosenberg Children's Medical Plaza - ENT/Otolaryngology	1920 E Cambridge Avenue	Phoenix	AZ	Terminated
PED033302-98	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Care ENT/Otolarngology - West Phoenix	9250 W Thomas Road	Phoenix	AZ	Terminated
PED033302-99	Child	PED	PHOENIX CHILDREN'S HOSPITAL	Phoenix Children's Specialty Clinic - Mercy Gilbert Medical Center - Urology	3370 S Mercy Road	Gilbert	AZ	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Jaffery, Syed Director of Pharmacy (Business Operations) Phoenix Children's Hospital 6029335185	Jaffery, Syed Director of Pharmacy Business Operations Phoenix Children's Hospital 6029335185	8/24/2022 6:36 PM
Details	State	Update		To Be Terminated	Terminated	4/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		3/31/2022 12:00:00 AM	3/15/2022 8:16 AM
Details	State	Update	Termination Request	Active	To Be Terminated	3/15/2022 8:16 AM
Terminations	Termination Comments	Update	Termination Request		Entity PED033302-104 was merged with entity PED033302-102. Terminating entity PED033302-104 to eliminate a duplicate registration. Entity PED033302-102 will remain active.	3/15/2022 8:16 AM
Terminations	Termination Date	Update	Termination Request		4/1/2022 12:00:00 AM	3/15/2022 8:16 AM
Terminations	Termination Effective Date	Update	Termination Request		4/1/2022 12:00:00 AM	3/15/2022 8:16 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	3/15/2022 8:16 AM
Contacts	Primary Contact	Update	Profile Change Request	Jaffery, Syed Director of Pharmacy (Business Operations) Phoenix Children's Hospital 3174468568	Jaffery, Syed Director of Pharmacy (Business Operations) Phoenix Children's Hospital 6029335185	3/3/2022 3:49 PM
Addresses	Main Address	Update	Change Request	1546 N Parkway Drive Suite 101 Gilbert, AZ 85234	1501 N Gilbert Road Suite 203 Gilbert, AZ 85296	1/13/2022 9:07 AM
Details	Entity Subname	Update	Change Request	Phoenix Children’s Pediatrics - Val Vista Lakes	Phoenix Children's Pediatrics	1/13/2022 9:07 AM
Contacts	Primary Contact	Update	Group Change Request	Dickman, Bethany Pharmacy Business Manager Phoenix Children's Hospital 6029334033	Jaffery, Syed Director of Pharmacy (Business Operations) Phoenix Children's Hospital 3174468568	12/30/2021 6:45 AM
Details	Last Recertification Date	Update	Recertification	9/1/2020 3:38:05 AM	9/8/2021 12:03:40 PM	9/8/2021 12:03 PM
Details	Last Recertification Date	Update	Recertification		9/1/2020 3:38:05 AM	9/1/2020 3:38 AM
Addresses	Main Address	Update	Change Request	1546 N. Parkway Drive Suite 101 Gilbert, AZ 85234	1546 N Parkway Drive Suite 101 Gilbert, AZ 85234	6/24/2020 8:52 AM
Contacts	Primary Contact	Update	Change Request	Douthard, Yolanda Chief of Pharmacy Services Phoenix Children's Hospital 6029331891	Dickman, Bethany Pharmacy Business Manager Phoenix Children's Hospital 6029334033	6/24/2020 8:52 AM
Details	Entity Subname	Update	Change Request	Phoenix Children’s Pediatrics - Val Vista Lakes - Primary Care Pediatrics	Phoenix Children’s Pediatrics - Val Vista Lakes	6/24/2020 8:52 AM
Details	State	Update		Approved	Active	1/1/2020 12:04 AM
Contacts	Signed By	Insert	New Registration		Cornicelli, Kari Executive Vice President and Chief Financial Officer Phoenix Children's Hospital 6029335468	11/15/2019 3:18 PM
Details	340B ID	Update	New Registration		PED033302-104	11/15/2019 3:18 PM
Details	Entity Name	Update	New Registration	PHOENIX CHILDRENS HOSPITAL	PHOENIX CHILDREN'S HOSPITAL	11/15/2019 3:18 PM
Details	Entity Subname	Update	New Registration	Phoenix Children’s Pediatrics - Val Vista Lakes	Phoenix Children’s Pediatrics - Val Vista Lakes - Primary Care Pediatrics	11/15/2019 3:18 PM
Dates	Participating Approval Date	Update	New Registration		11/15/2019 3:18:50 PM	11/15/2019 3:18 PM
Details	State	Update	New Registration	Pending	Approved	11/15/2019 3:18 PM
Dates	Signed By Date	Update	New Registration		11/6/2019 8:58:16 PM	11/15/2019 3:18 PM
Dates	Start Date	Update	New Registration		1/1/2020 12:00:00 AM	11/15/2019 3:18 PM
Addresses	Main Address	Insert	New Registration		1546 N. Parkway Drive Suite 101 Gilbert, AZ 85234	10/11/2019 7:54 PM
Contacts	Primary Contact	Insert	New Registration		Douthard, Yolanda Chief of Pharmacy Services Phoenix Children's Hospital 6029331891	10/11/2019 7:54 PM
Contacts	Authorizing Official	Insert	New Registration		Cornicelli, Kari Executive Vice President and Chief Financial Officer Phoenix Children's Hospital 6029335468	10/11/2019 7:54 PM
Details	Last Recertification Date	Insert	New Registration			10/11/2019 7:54 PM
Details	Grant Number	Insert	New Registration			10/11/2019 7:54 PM
Details	340B ID	Insert	New Registration			10/11/2019 7:54 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/11/2019 7:54 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/11/2019 7:54 PM
Details	Medicare Provider Number	Insert	New Registration		033302	10/11/2019 7:54 PM
Details	Entity Name	Insert	New Registration		PHOENIX CHILDRENS HOSPITAL	10/11/2019 7:54 PM
Details	Program Code	Insert	New Registration		PED	10/11/2019 7:54 PM
Details	Entity Subname	Insert	New Registration		Phoenix Children’s Pediatrics - Val Vista Lakes	10/11/2019 7:54 PM
Dates	Participating Approval Date	Insert	New Registration			10/11/2019 7:54 PM
Details	State	Insert	New Registration		Pending	10/11/2019 7:54 PM
Dates	Registration Date	Insert	New Registration		10/11/2019 7:54:17 PM	10/11/2019 7:54 PM
Dates	Signed By Date	Insert	New Registration			10/11/2019 7:54 PM
Dates	Start Date	Insert	New Registration			10/11/2019 7:54 PM
Terminations	Termination Comments	Insert	New Registration			10/11/2019 7:54 PM
Terminations	Termination Date	Insert	New Registration			10/11/2019 7:54 PM
Terminations	Termination Effective Date	Insert	New Registration			10/11/2019 7:54 PM
Terminations	Termination Reason	Insert	New Registration			10/11/2019 7:54 PM