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WAL-MART PHARMACY 10-2768
DSH030065 BANNER DESERT MEDICAL CENTER
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Covered Entity Details
Entity Name
BANNER DESERT MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030065
Entity Address
1400 SOUTH DOBSON ROAD
MESA, AZ 85202
Medicare Provider Number
030065
Participating Start Date
1/1/2007
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2768
Pharmacy Address
1955 SO. STAPLEY DRIVE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
5/31/2012
Contract Begin Date
5/31/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/15/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Dennis Dahlen, Senior Vice President, CFO
(602) 747-4727
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
5/3/2012
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