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SAFEWAY INC
DSH030065 BANNER DESERT MEDICAL CENTER
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Covered Entity Details
Entity Name
BANNER DESERT MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030065
Entity Address
1400 SOUTH DOBSON ROAD
MESA, AZ 85202
Medicare Provider Number
030065
Participating Start Date
1/1/2007
Last Recertification Date
8/12/2024
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
10/26/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/6/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Cheryl A Tong, CFO
(602) 865-5751
Contract Pharmacy Representative
SAFEWAY
Charles Hanson, 340B Program Manager
(208) 395-6304
Signed By Date
10/26/2018
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