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GOODYEAR CVS, L.L.C.
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
GOODYEAR CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 03749
2840 N. DYSART RD.
GOODYEAR, AZ 85395
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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