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BANNER FAMILY PHARMACY-CHANDLER
CAH031304-00 Page Hospital
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Covered Entity Details
Entity Name
Page Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031304-00
Entity Address
501 North Navajo
Page, AZ 86040
Medicare Provider Number
031304
Participating Start Date
4/1/2012
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
BANNER FAMILY PHARMACY-CHANDLER
Pharmacy Address
7300 W DETROIT ST
CHANDLER, AZ 85226-2410
Pharmacy Comments
Contract Details
Approval Date
7/14/2015
Contract Begin Date
10/1/2015
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
Sandy Haryasz, CEO
(928) 645-0115
Contract Pharmacy Representative
Wesam Hammad, Pharmacist in Charge
(602) 747-6459
Signed By Date
7/14/2015
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