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BANNER FAMILY PHARMACY-CHANDLER
DSH030016 Banner Casa Grande Medical Center
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Covered Entity Details
Entity Name
Banner Casa Grande Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030016
Entity Address
1800 East Florence Blvd.
Casa Grande, AZ 85122
Medicare Provider Number
030016
Participating Start Date
10/1/2013
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
BANNER FAMILY PHARMACY-CHANDLER
Pharmacy Address
7300 W DETROIT ST
CHANDLER, AZ 85226-2410
Pharmacy Comments
Contract Details
Approval Date
10/13/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/4/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Robert Bender, Chief Financial Officer
(520) 381-6529
Contract Pharmacy Representative
Wesam Hammad, Pharmacist in Charge
(602) 747-6459
Signed By Date
10/13/2015
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