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BANNER FAMILY PHARMACY - DESERT
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
BANNER FAMILY PHARMACY - DESERT
Pharmacy Address
1400 S DOBSON ROAD
MESA, AZ 85202-4707
Pharmacy Comments
Contract Details
Approval Date
1/13/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
SCOTT LECKEY, CFO
(480) 412-3214
Contract Pharmacy Representative
Banner Health
Russell Funk, CEO Banner Pharmacy Services
(602) 747-4197
Signed By Date
1/13/2014
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