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WALGREEN ARIZONA DRUG CO.
DSH030130 Banner Ironwood Medical Center
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Covered Entity Details
Entity Name
Banner Ironwood Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030130
Entity Address
37000 N. Gantzel Road
Queen Creek, AZ 85140
Medicare Provider Number
030130
Participating Start Date
4/1/2012
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
WALGREEN ARIZONA DRUG CO.
Pharmacy Address
DBA; WALGREENS #09460
40663 N. GANTZEL RD
SAN TAN VALLEY, AZ 85140-7008
Pharmacy Comments
Contract Details
Approval Date
12/19/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/11/2016
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
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
12/19/2012
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