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PED033302-64 PHOENIX CHILDREN'S HOSPITAL (Terminated)
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Main Details
Name
PHOENIX CHILDREN'S HOSPITAL
Subdivision Name
Phoenix Children's Specialty Care Rosenberg - Infusion Center
Type
Children's Hospital
Rural
No
340B ID
PED033302-64
Medicare Provider Number
033302
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
7/10/2015
Participating Start Date
10/1/2015
Participating Approval Date
8/13/2015
Last Recertification Date
9/1/2020
Termination Date
Termination Reason
10/1/2021
Site closure
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
Bethany Dickman, Pharmacy Business Manager
(602) 933-4033
Addresses
Street Address
1920 E Cambridge Avenue
Suite 100
Phoenix, AZ 85006
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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