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KING TUT PHARMACY
CAH031312-02 Bisbee Hospital Association dba Copper Queen Community Hospital
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Covered Entity Details
Entity Name
Bisbee Hospital Association dba Copper Queen Community Hospital
Subdivision Name
Palominas Hereford Rural Health Clinic
Type
Critical Access Hospital
340B ID
CAH031312-02
Entity Address
10524 Highway 92
Hereford, AZ 85615
Medicare Provider Number
031312
Outpatient Facility Provider Number
033996
Participating Start Date
7/1/2013
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
KING TUT PHARMACY
Pharmacy Address
90 E 3RD ST
SUITE B
DOUGLAS, AZ 85607
Pharmacy Comments
Contract Details
Approval Date
10/9/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Heather A Lundstrom, Chief Financial Officer
(520) 432-6450
Contract Pharmacy Representative
King Tut Pharmacy
Kariem Ismail, owner/pic
(520) 220-1281
Signed By Date
10/9/2018
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