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ARIZONA CVS STORES, L.L.C.
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
ARIZONA CVS STORES, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 09256
3560 WEST PEORIA AVENUE
PHOENIX, AZ 85029
Pharmacy Comments
Contract Details
Approval Date
3/13/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/15/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Dave Kaubisch, Vice President of Finance
(602) 747-4556
Contract Pharmacy Representative
John R. Zevzavadjian, Vice President, Managed Care
(401) 770-5503
Signed By Date
1/15/2013
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