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SAFEWAY INC
DSH030122 BANNER GATEWAY MEDICAL CENTER
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Covered Entity Details
Entity Name
BANNER GATEWAY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030122
Entity Address
1900 NORTH HIGLEY ROAD
GILBERT, AZ 85234
Medicare Provider Number
030122
Participating Start Date
10/1/2015
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #0253
3185 W. APACHE TRAIL
APACHE JUNCTION, AZ 85120
Pharmacy Comments
Contract Details
Approval Date
10/11/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/16/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Matthew P Huff, CFO
(480) 543-2277
Contract Pharmacy Representative
SAFEWAY
Charles Hanson, 340B Program Manager
(208) 395-6304
Signed By Date
10/11/2018
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