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SAFEWAY INC
DSH030115 BANNER ESTRELLA MEDICAL CENTER
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Covered Entity Details
Entity Name
BANNER ESTRELLA MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030115
Entity Address
9201 WEST THOMAS ROAD
PHOENIX, AZ 85037
Medicare Provider Number
030115
Participating Start Date
7/1/2007
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #2618
440 N ESTRELLA PARKWAY
GOODYEAR, AZ 85338
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/22/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Patricia Rhoden, Chief Financial Officer
(602) 839-8507
Contract Pharmacy Representative
SAFEWAY
Charles Hanson, 340B Program Manager
(208) 395-6304
Signed By Date
10/15/2018
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