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BANNER FAMILY PHARMACY-CHANDLER
CAH051320-00 BANNER LASSEN MEDICAL CENTER
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Covered Entity Details
Entity Name
BANNER LASSEN MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH051320-00
Entity Address
1800 SPRING RIDGE DRIVE
SUSANVILLE, CA 96130
Medicare Provider Number
051320
Participating Start Date
9/20/2010
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
BANNER FAMILY PHARMACY-CHANDLER
Pharmacy Address
7300 W DETROIT ST
CHANDLER, AZ 85226-2410
Pharmacy Comments
Contract Details
Approval Date
10/28/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/1/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jon McMillan, CFO of BLMC
(530) 252-2239
Contract Pharmacy Representative
Wesam Hammad, Pharmacist in Charge
(602) 747-6459
Signed By Date
10/28/2015
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