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PED033302-35 PHOENIX CHILDREN'S HOSPITAL (Terminated)
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Main Details
Name
PHOENIX CHILDREN'S HOSPITAL
Subdivision Name
Phoenix Children's Specialty Clinic (Rosenberg Building) PCMG Gynecology
Type
Children's Hospital
Rural
No
340B ID
PED033302-35
Medicare Provider Number
033302
Outpatient Facility Provider Number
033302
Additional Details
Current Program Status
Terminated
Registration Date
7/15/2014
Participating Start Date
10/1/2014
Participating Approval Date
9/4/2014
Last Recertification Date
9/6/2018
Termination Date
Termination Reason
10/1/2019
Outpatient facility moved within the 4 walls of the parent hospital
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
Yolanda Douthard, Chief of Pharmacy Services
(602) 933-1891
Addresses
Street Address
1920 E Cambridge Avenue
Suite 304
Phoenix, AZ 85016
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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