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BANNER FAMILY PHARMACY-UNIV MED INSTITUT
DSH030016 Banner Casa Grande Medical Center
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Covered Entity Details
Entity Name
Banner Casa Grande Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030016
Entity Address
1800 East Florence Blvd.
Casa Grande, AZ 85122
Medicare Provider Number
030016
Participating Start Date
10/1/2013
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
BANNER FAMILY PHARMACY-UNIV MED INSTITUT
Pharmacy Address
ATTN: PHARMACY DEPARTMENT
1441 N 12TH ST
PHOENIX, AZ 85006
Pharmacy Comments
Contract Details
Approval Date
10/14/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Louis Schroeder, Chief Financial Officer
(520) 381-6529
Contract Pharmacy Representative
Banner Health
Russell Funk, CEO Banner Pharmacy Services
(602) 747-4197
Signed By Date
10/14/2024
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