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SMITHS FOOD & DRUG CENTER
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
SMITHS FOOD & DRUG CENTER
Pharmacy Address
DBA FRYS FOOD & DRUG #20
3640 S 16 AVENUE
TUCSON, AZ 85713
Pharmacy Comments
Contract Details
Approval Date
4/12/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Misty Hansen, CFO
(520) 694-4091
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
4/12/2013
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