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GERMAN DOBSON CVS, L.L.C.
DSH030089 BANNER THUNDERBIRD MEDICAL CENTER
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Covered Entity Details
Entity Name
BANNER THUNDERBIRD MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030089
Entity Address
5555 W. Thunderbird Road
Glendale, AZ 85306
Medicare Provider Number
030089
Participating Start Date
1/1/2007
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
GERMAN DOBSON CVS, L.L.C.
Pharmacy Address
CVS PHARMACY # 17418
5715 N 19TH AVE
PHOENIX, AZ 85015
Pharmacy Comments
Contract Details
Approval Date
7/5/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jeremy Williams, Chief Financial Officer
(623) 524-4083
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/5/2020
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