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PRIME THERAPEUTICS SPECIALTY PHARMACY LL
CAH031318-00 BANNER PAYSON MEDICAL CENTER
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Covered Entity Details
Entity Name
BANNER PAYSON MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031318-00
Entity Address
807 S. PONDEROSA
PAYSON, AZ 85541
Medicare Provider Number
031318
Participating Start Date
1/1/2020
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
PRIME THERAPEUTICS SPECIALTY PHARMACY LL
Pharmacy Address
ALLIANCERX WALGREENS PRIME #16568
2354 COMMERCE PARK DRIVE
SUITE 100
ORLANDO, FL 32819-9992
Pharmacy Comments
Contract Details
Approval Date
1/9/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/9/2022
Business decision by covered entity and/or pharmacy
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
1/9/2020
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