Contract Pharmacy Details

ALBERTSON'S LLC
DSH030089 BANNER THUNDERBIRD MEDICAL CENTER

Covered Entity Details

Entity Name

BANNER THUNDERBIRD MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH030089

Entity Address

5555 W. Thunderbird Road
Glendale, AZ 85306

Medicare Provider Number

030089

Participating Start Date

1/1/2007

Last Recertification Date

8/30/2024

Pharmacy Details

Pharmacy Name

ALBERTSON'S LLC

Pharmacy Address

OSCO DRUG #3941
5040 WEST CACTUS RD
GLENDALE, AZ 85304

Pharmacy Comments

Contract Details

Approval Date

10/19/2018

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

Jeremy Williams, Chief Financial Officer
(623) 524-4083

Contract Pharmacy Representative

SAFEWAY
Charles Hanson, 340B Program Manager
(208) 395-6304

Signed By Date

10/19/2018

340B Drug Pricing Program Database