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WALGREEN CO
DSH030002 Banner – University Medical Center Phoenix
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Covered Entity Details
Entity Name
Banner – University Medical Center Phoenix
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030002
Entity Address
1111 EAST MCDOWELL ROAD
PHOENIX, AZ 85006
Medicare Provider Number
030002
Participating Start Date
9/9/2005
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO
Pharmacy Address
DBA: WALGREENS
17500 PERRIS BLVD
MORENO VALLEY, CA 92551-9547
Pharmacy Comments
Contract Details
Approval Date
12/21/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/17/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Cliff Loader, Chief Financial Officer
(602) 839-2675
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
12/21/2012
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