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SAFEWAY PHARMACY #2058
DSH030089 BANNER THUNDERBIRD MEDICAL CENTER
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Covered Entity Details
Entity Name
BANNER THUNDERBIRD MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030089
Entity Address
5555 W. Thunderbird Road
Glendale, AZ 85306
Medicare Provider Number
030089
Participating Start Date
1/1/2007
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
SAFEWAY PHARMACY #2058
Pharmacy Address
5080 WEST OLIVE
GLENDALE, AZ 85302
Pharmacy Comments
Contract Details
Approval Date
9/21/2012
Contract Begin Date
9/21/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/15/2016
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
Safeway
Merle Jarvill, Director, Managed Care
(623) 869-4260
Signed By Date
8/30/2012
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