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SAFEWAY INC
DSH030115 BANNER ESTRELLA MEDICAL CENTER
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Covered Entity Details
Entity Name
BANNER ESTRELLA MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030115
Entity Address
9201 WEST THOMAS ROAD
PHOENIX, AZ 85037
Medicare Provider Number
030115
Participating Start Date
7/1/2007
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1662
10641 W. OLIVE AVENUE
PEORIA, AZ 85345
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
3/18/2016
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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