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SAFEWAY INC
DSH030130 Banner Ironwood Medical Center
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Covered Entity Details
Entity Name
Banner Ironwood Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030130
Entity Address
37000 N. Gantzel Road
Queen Creek, AZ 85140
Medicare Provider Number
030130
Participating Start Date
4/1/2012
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #2835
3325 NORTH HUNT HIGHWAY
FLORENCE, AZ 85132
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
7/5/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeff Allen Buehrle, CFO
(480) 394-4396
Contract Pharmacy Representative
SAFEWAY
Charles Hanson, 340B Program Manager
(208) 395-6304
Signed By Date
10/15/2018
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