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GENOA HEALTHCARE LLC
DSH030122 BANNER GATEWAY MEDICAL CENTER
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Covered Entity Details
Entity Name
BANNER GATEWAY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030122
Entity Address
1900 NORTH HIGLEY ROAD
GILBERT, AZ 85234
Medicare Provider Number
030122
Participating Start Date
10/1/2015
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
GENOA HEALTHCARE LLC
Pharmacy Address
1101 NORTH CENTRAL AVE
STE 102
PHOENIX, AZ 85004
Pharmacy Comments
Contract Details
Approval Date
1/17/2022
Contract Begin Date
1/24/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Cody W Ziemer, Chief Financial Officer
(602) 839-8507
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/17/2022
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