Contract Pharmacy Details

ALBERTSON'S LLC
DSH030111 Banner – University Medical Center South

Covered Entity Details

Entity Name

Banner – University Medical Center South

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH030111

Entity Address

2800 EAST AJO WAY
TUCSON, AZ 85713

Medicare Provider Number

030111

Participating Start Date

4/1/2006

Last Recertification Date

8/12/2024

Pharmacy Details

Pharmacy Name

ALBERTSON'S LLC

Pharmacy Address

OSCO DRUG #3964
9595 E BROADWAY BLVD
TUCSON, AZ 85748

Pharmacy Comments

Contract Details

Approval Date

1/16/2019

Contract Begin Date

4/1/2019

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

3/21/2022
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Sarah Frost, Chief Operating Officer
(520) 694-3445

Contract Pharmacy Representative

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

Signed By Date

1/16/2019

340B Drug Pricing Program Database