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CYSTIC FIBROSIS SERVICES, LLC
DSH030130 Banner Ironwood Medical Center
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Covered Entity Details
Entity Name
Banner Ironwood Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030130
Entity Address
37000 N. Gantzel Road
Queen Creek, AZ 85140
Medicare Provider Number
030130
Participating Start Date
4/1/2012
Last Recertification Date
8/12/2024
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
10/15/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jeff Allen Buehrle, CFO
(480) 394-4396
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/15/2019
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