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WALGREEN ARIZONA DRUG CO.
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
WALGREEN ARIZONA DRUG CO.
Pharmacy Address
WALGREENS CENTRAL FILL #21372
120 N 83RD AVE
STE 200
TOLLESON, AZ 85353
Pharmacy Comments
Contract Details
Approval Date
10/14/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
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
10/14/2021
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