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BANNER FAMILY PHARMACY-CHANDLER
DSH020012 FAIRBANKS MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
FAIRBANKS MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH020012
Entity Address
1650 COWLES STREET
FAIRBANKS, AK 99701-5998
Medicare Provider Number
020012
Participating Start Date
9/9/2005
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
BANNER FAMILY PHARMACY-CHANDLER
Pharmacy Address
7300 W DETROIT ST
CHANDLER, AZ 85226-2410
Pharmacy Comments
Contract Details
Approval Date
7/27/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/1/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jim Lynch, CFO
(907) 458-5300
Contract Pharmacy Representative
Wesam Hammad, Pharmacist in Charge
(602) 747-6459
Signed By Date
7/27/2015
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