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GERMAN DOBSON CVS, L.L.C.
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
GERMAN DOBSON CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 05814
9950 E. GUADALUPE RD.
MESA, AZ 85212
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
4/14/2015
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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