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CYSTIC FIBROSIS SERVICES, LLC
DSH030024 ST JOSEPH'S HOSPITAL AND MEDICAL CENTER
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Covered Entity Details
Entity Name
ST JOSEPH'S HOSPITAL AND MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030024
Entity Address
350 W THOMAS ROAD
PHOENIX, AZ 85013
Medicare Provider Number
030024
Participating Start Date
1/1/2005
Last Recertification Date
8/18/2024
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
10/9/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/30/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeffrey Jackson, Chief Financial Officer
(602) 406-4618
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/9/2019
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