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BRIOVARX OF MAINE INC
DSH030064 Banner - University Medical Center Tucson
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Covered Entity Details
Entity Name
Banner - University Medical Center Tucson
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030064
Entity Address
1625 North Campbell Avenue
TUCSON, AZ 85719
Medicare Provider Number
030064
Participating Start Date
1/1/1997
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
BRIOVARX OF MAINE INC
Pharmacy Address
DBA BRIOVARX
53 DARLING AVE
SOUTH PORTLAND, ME 04106
Pharmacy Comments
Contract Details
Approval Date
4/17/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Sarah Frost, Chief Operating Officer
(520) 694-3445
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
4/17/2019
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