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SAFEWAY INC
DSH030111 Banner – University Medical Center South
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Covered Entity Details
Entity Name
Banner – University Medical Center South
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030111
Entity Address
2800 EAST AJO WAY
TUCSON, AZ 85713
Medicare Provider Number
030111
Participating Start Date
4/1/2006
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #0255
1551 W ST MARYS RD
TUCSON, AZ 85745
Pharmacy Comments
Contract Details
Approval Date
7/20/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Maurene Polashek, Sr Dir Finance
(520) 694-3446
Contract Pharmacy Representative
Albertsons
Ronald Richmon, Group Director of Managed Care
(630) 948-6285
Signed By Date
7/20/2018
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