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CYSTIC FIBROSIS SERVICES, LLC
DSH060001 Banner North Colorado Medical Center
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Covered Entity Details
Entity Name
Banner North Colorado Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060001
Entity Address
1801 16th Street
Greeley, CO 80631
Medicare Provider Number
060001
Participating Start Date
10/1/2013
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
4/16/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Krista Touros, CFO - Western Division
(970) 810-1567
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/16/2019
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