Covered Entity Details

CAH031301-01 BENSON HOSPITAL (Active) - information as of 6/14/2025 10:07:38 AM

Main Details

Name

BENSON HOSPITAL

Subdivision Name

Family HealthCare Clinic - Primary Care

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH031301-01

Medicare Provider Number

031301

Outpatient Facility Provider Number

038508

Additional Details

Current Program Status

Active

Registration Date

3/23/2021

Participating Start Date

3/24/2021

Participating Approval Date

3/24/2021

Last Recertification Date

8/14/2024

Contacts

Authorizing Official

Benson Hospital
Gary Kartchner, CEO
(520) 720-6606

Primary Contact

Benson Hospital
Bret Hicks, CFO
(520) 720-6508

Addresses

Street Address

688 W 4th St
Benson, AZ 85602

Billing Address

Benson Hospital
450 S Ocotillo Road
Benson, AZ 85602

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
CAH031301-01	Child	CAH	BENSON HOSPITAL	Family HealthCare Clinic - Primary Care	688 W 4th St	Benson	AZ	Active
CAH031301-02	Child	CAH	BENSON HOSPITAL	San Pedro Clinic - Primary Care - San Pedro Clinic - Primary Care	890 W 4th St	Benson	AZ	Active
CAH031301-03	Child	CAH	BENSON HOSPITAL	Vail Valley Clinic - Vail Valley (Family Practice)	13370 E Mary Ann Cleveland Way #102	Vail	AZ	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/18/2023 12:40:02 PM	8/14/2024 1:45:14 PM	8/14/2024 1:45 PM
Contacts	Authorizing Official	Update	Change Request	Strange, Julia CEO Benson Hospital 5207206543	Kartchner, Gary CEO Benson Hospital 5207206606	12/18/2023 1:57 PM
Details	Last Recertification Date	Update	Recertification	8/30/2022 6:31:51 PM	8/18/2023 12:40:02 PM	8/18/2023 12:40 PM
Details	Last Recertification Date	Update	Recertification	8/18/2021 1:39:10 PM	8/30/2022 6:31:51 PM	8/30/2022 6:31 PM
Contacts	Authorizing Official	Update	Change Request	Vincifora, Teresa COO Benson Hospital 5207206510	Strange, Julia CEO Benson Hospital 5207206543	1/20/2022 2:37 PM
Details	Last Recertification Date	Update	Recertification		8/18/2021 1:39:10 PM	8/18/2021 1:39 PM
Details	State	Update	OPA Edit	Approved	Active	3/24/2021 7:18 PM
Dates	Start Date	Update	OPA Edit	4/1/2021 12:00:00 AM	3/24/2021 12:00:00 AM	3/24/2021 7:18 PM
Contacts	Signed By	Insert	New Registration		Vincifora, Teresa COO Benson Hospital 5207206510	3/24/2021 3:08 PM
Details	340B ID	Update	New Registration		CAH031301-01	3/24/2021 3:08 PM
Details	Entity Subname	Update	New Registration	Family HealthCare Clinic	Family HealthCare Clinic - Primary Care	3/24/2021 3:08 PM
Dates	Participating Approval Date	Update	New Registration		3/24/2021 3:08:40 PM	3/24/2021 3:08 PM
Details	State	Update	New Registration	Pending	Approved	3/24/2021 3:08 PM
Dates	Signed By Date	Update	New Registration		3/24/2021 1:17:08 PM	3/24/2021 3:08 PM
Dates	Start Date	Update	New Registration		4/1/2021 12:00:00 AM	3/24/2021 3:08 PM
Addresses	Main Address	Insert	New Registration		688 W 4th St Benson, AZ 85602	3/23/2021 12:42 PM
Addresses	Billing Address	Insert	New Registration		Benson Hospital 450 S Ocotillo Road Benson, AZ 85602	3/23/2021 12:42 PM
Contacts	Primary Contact	Insert	New Registration		Hicks, Bret CFO Benson Hospital 5207206508	3/23/2021 12:42 PM
Contacts	Authorizing Official	Insert	New Registration		Vincifora, Teresa COO Benson Hospital 5207206510	3/23/2021 12:42 PM
Details	Assistance Received From Date	Insert	New Registration			3/23/2021 12:42 PM
Details	Assistance Received To Date	Insert	New Registration			3/23/2021 12:42 PM
Details	Last Recertification Date	Insert	New Registration			3/23/2021 12:42 PM
Details	Grant Number	Insert	New Registration			3/23/2021 12:42 PM
Details	340B ID	Insert	New Registration			3/23/2021 12:42 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			3/23/2021 12:42 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			3/23/2021 12:42 PM
Details	Medicare Provider Number	Insert	New Registration		031301	3/23/2021 12:42 PM
Details	Entity Name	Insert	New Registration		BENSON HOSPITAL	3/23/2021 12:42 PM
Details	NOFO Number	Insert	New Registration			3/23/2021 12:42 PM
Details	Program Code	Insert	New Registration		CAH	3/23/2021 12:42 PM
Details	Entity Subname	Insert	New Registration		Family HealthCare Clinic	3/23/2021 12:42 PM
Dates	Participating Approval Date	Insert	New Registration			3/23/2021 12:42 PM
Details	State	Insert	New Registration		Pending	3/23/2021 12:42 PM
Dates	Registration Date	Insert	New Registration		3/23/2021 12:42:51 PM	3/23/2021 12:42 PM
Dates	Signed By Date	Insert	New Registration			3/23/2021 12:42 PM
Dates	Start Date	Insert	New Registration			3/23/2021 12:42 PM
Terminations	Termination Comments	Insert	New Registration			3/23/2021 12:42 PM
Terminations	Termination Date	Insert	New Registration			3/23/2021 12:42 PM
Terminations	Termination Effective Date	Insert	New Registration			3/23/2021 12:42 PM
Terminations	Termination Reason	Insert	New Registration			3/23/2021 12:42 PM