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GENOA HEALTHCARE LLC
DSH030089 BANNER THUNDERBIRD MEDICAL CENTER
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Covered Entity Details
Entity Name
BANNER THUNDERBIRD MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030089
Entity Address
5555 W. Thunderbird Road
Glendale, AZ 85306
Medicare Provider Number
030089
Participating Start Date
1/1/2007
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
GENOA HEALTHCARE LLC
Pharmacy Address
1101 NORTH CENTRAL AVE
STE 102
PHOENIX, AZ 85004
Pharmacy Comments
Contract Details
Approval Date
4/11/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/29/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Paul Vachek, CFO - BDMC
(480) 412-3214
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/11/2022
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