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AZ PHARMACY, LLC
DSH150021 Parkview Hospital
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Covered Entity Details
Entity Name
Parkview Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150021
Entity Address
11109 PARKVIEW PLAZA DRIVE
FORT WAYNE, IN 46845
Medicare Provider Number
150021
Participating Start Date
10/1/2015
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
AZ PHARMACY, LLC
Pharmacy Address
DBA AMAZON PHARMACY #002
3809 E WATKINS ST
PHOENIX, AZ 85034
Pharmacy Comments
Contract Details
Approval Date
10/17/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/11/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeanne Wickens, CFO
(260) 373-8407
Contract Pharmacy Representative
Equiscript
Josh Thomas, CEO
(843) 300-1930
Signed By Date
10/17/2022
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