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BANNER FAMILY PHARMACY - TUCSON NORTH CA
DSH030111 Banner – University Medical Center South
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Covered Entity Details
Entity Name
Banner – University Medical Center South
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030111
Entity Address
2800 EAST AJO WAY
TUCSON, AZ 85713
Medicare Provider Number
030111
Participating Start Date
4/1/2006
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
BANNER FAMILY PHARMACY - TUCSON NORTH CA
Pharmacy Address
3838 N CAMPBELL AVE
STE 2112
TUCSON, AZ 85719
Pharmacy Comments
Contract Details
Approval Date
1/14/2022
Contract Begin Date
1/28/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brad Hipp, Chief Financial Officer
(520) 694-3446
Contract Pharmacy Representative
Banner Health
Russell Funk, CEO Banner Pharmacy Services
(602) 747-4197
Signed By Date
1/14/2022
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