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CYSTIC FIBROSIS SERVICES, LLC
RRC030119-00 MERCY GILBERT MEDICAL CENTER
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Covered Entity Details
Entity Name
MERCY GILBERT MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC030119-00
Entity Address
3555 S. VAL VISTA DRIVE
GILBERT, AZ 85297
Medicare Provider Number
030119
Participating Start Date
4/1/2018
Last Recertification Date
8/24/2023
Entity Termination Date
4/1/2024
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
10/14/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/15/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Eric Sorensen, CFO
(480) 728-3144 Ext: 4807283144
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/14/2019
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