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WALGREEN ARIZONA DRUG CO.
SCH030033-00 Banner Payson Medical Center
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Covered Entity Details
Entity Name
Banner Payson Medical Center
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH030033-00
Entity Address
807 S. PONDEROSA STREET
PAYSON, AZ 85541
Medicare Provider Number
030033
Participating Start Date
10/1/2016
Last Recertification Date
8/28/2019
Entity Termination Date
10/1/2019
Pharmacy Details
Pharmacy Name
WALGREEN ARIZONA DRUG CO.
Pharmacy Address
DBA: WALGREENS # 06533
100 S BEELINE HWY
PAYSON, AZ 85541-4809
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
10/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Matthew K King, Senior Finance Director
(801) 682-9661
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/17/2019
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