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GERMAN DOBSON CVS, L.L.C.
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
GERMAN DOBSON CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 01720
21201 EAST OCOTILLO RD.,
QUEEN CREEK, AZ 85142
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jeff Allen Buehrle, CFO
(480) 394-4396
Contract Pharmacy Representative
Caremark L.L.C.
Christian reid, 340b Program Director
(401) 770-2118
Signed By Date
1/15/2020
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