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ALBERTSON'S LLC
DSH030022 MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT
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Covered Entity Details
Entity Name
MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030022
Entity Address
MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT DBA VALLEYWISE HEALTH
2601 EAST ROOSEVELT STREET
PHOENIX, AZ 85008
Medicare Provider Number
030022
Participating Start Date
10/4/2018
Last Recertification Date
8/24/2024
Pharmacy Details
Pharmacy Name
ALBERTSON'S LLC
Pharmacy Address
OSCO DRUG #980
1951 W BASELINE
MESA, AZ 85202
Pharmacy Comments
Contract Details
Approval Date
10/5/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/12/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kris Gaw, Chief Operating Officer
(602) 344-1258
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
10/5/2018
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