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CORAM ALTERNATE SITE SERVICES, INC
DSH030122 BANNER GATEWAY MEDICAL CENTER
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Covered Entity Details
Entity Name
BANNER GATEWAY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030122
Entity Address
1900 NORTH HIGLEY ROAD
GILBERT, AZ 85234
Medicare Provider Number
030122
Participating Start Date
10/1/2015
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
CORAM ALTERNATE SITE SERVICES, INC
Pharmacy Address
DBA CORAM CVS/SPECIALTY INFUSION SERVICE
12310 WORLD TRADE DRIVE
SUITE 100
SAN DIEGO, CA 92128
Pharmacy Comments
Contract Details
Approval Date
1/15/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ana Barraza, CFO
(480) 543-2277
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/15/2025
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