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DSH030089D BANNER THUNDERBIRD MEDICAL CENTER (Active)
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Main Details
Name
BANNER THUNDERBIRD MEDICAL CENTER
Subdivision Name
BANNER THUNDERBIRD MEDICAL CENTER - PEDIATRIC OUTPATIENT CLINIC - PEDS HEMO ONC-HOSP
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH030089D
Medicare Provider Number
030089
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
10/4/2022
Participating Start Date
1/1/2023
Participating Approval Date
11/7/2022
Last Recertification Date
8/12/2024
Contacts
Authorizing Official
Banner Desert Medical Center
Paul Vachek, CFO - BDMC
(480) 412-3214
Primary Contact
Banner Thunderbird Medical Center
Theodore W Graphos, Director, Pharmacy
(602) 865-5709
Addresses
Street Address
5757 WEST THUNDERBIRD ROAD SUITE E250
GLENDALE, AZ 85306
Billing Address
BANNER ACCOUNTS PAYABLE
PO BOX 2977
PHOENIX, AZ 85062
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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