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WAL-MART PHARMACY 10-1612
DSH030064 Banner - University Medical Center Tucson
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Covered Entity Details
Entity Name
Banner - University Medical Center Tucson
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030064
Entity Address
1625 North Campbell Avenue
TUCSON, AZ 85719
Medicare Provider Number
030064
Participating Start Date
1/1/1997
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1612
Pharmacy Address
1650 WEST VALENCIA
TUCSON, AZ 85746
Pharmacy Comments
Contract Details
Approval Date
2/28/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/11/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Misty Hansen, CFO
(520) 694-4091
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
3/1/2013
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