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WALGREEN ARIZONA DRUG CO.
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
WALGREEN ARIZONA DRUG CO.
Pharmacy Address
DBA: WALGREENS # 04228
5125 W. NORTHERN AVE.
GLENDALE, AZ 85301
Pharmacy Comments
Contract Details
Approval Date
12/21/2012
Contract Begin Date
1/1/2013
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
Katy Kotin, CFO
(602) 865-5751
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
12/21/2012
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