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MELROSE PHARMACY
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
MELROSE PHARMACY
Pharmacy Address
706 W. MONTECITO AVE
PHOENIX, AZ 85013
Pharmacy Comments
Contract Details
Approval Date
3/13/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/23/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Cliff Loader, Chief Financial Officer
(602) 839-2675
Contract Pharmacy Representative
Melrose Pharmacy
Teresa Stickler, Owner/Rph
(602) 277-4714
Signed By Date
1/15/2013
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