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SMITHS FOOD & DRUG CENTERS
CAH031312-04 Bisbee Hospital Association dba Copper Queen Community Hospital
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Covered Entity Details
Entity Name
Bisbee Hospital Association dba Copper Queen Community Hospital
Subdivision Name
Copper Valley Home Health
Type
Critical Access Hospital
340B ID
CAH031312-04
Entity Address
101 Cole Ave
Bisbee, AZ 85603
Medicare Provider Number
031312
Outpatient Facility Provider Number
037179
Participating Start Date
1/1/2017
Last Recertification Date
8/16/2021
Entity Termination Date
10/1/2022
Pharmacy Details
Pharmacy Name
SMITHS FOOD & DRUG CENTERS
Pharmacy Address
DBA FRYS FOOD & DRUG #59
4351 E HIGHWAY 90
SIERRA VISTA, AZ 85635
Pharmacy Comments
Contract Details
Approval Date
4/1/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Heather A Lundstrom, Chief Financial Officer
(520) 432-6450
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
4/1/2019
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