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SMITH'S FOOD AND DRUG
DSH030023 FLAGSTAFF MEDICAL CENTER
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Covered Entity Details
Entity Name
FLAGSTAFF MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030023
Entity Address
1200 NORTH BEAVER
FLAGSTAFF, AZ 86001
Medicare Provider Number
030023
Participating Start Date
7/1/2009
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
SMITH'S FOOD AND DRUG
Pharmacy Address
DBA FRY'S FOOD AND DRUG #104
201 NORTH SWITZER CANYON DRIVE
FLAGSTAFF, AZ 86001
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/14/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Clifford F Loader, Chief Financial Officer
(928) 773-2282
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
7/15/2020
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