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BANNER FAMILY PHARMACY - CASA GRANDE
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 - CASA GRANDE
Pharmacy Address
1800 E FLORENCE BLVD
CASA GRANDE, AZ 85122
Pharmacy Comments
Contract Details
Approval Date
1/15/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Robert Bender, Chief Financial Officer
(520) 381-6529
Contract Pharmacy Representative
Banner Health
Russell Funk, CEO Banner Pharmacy Services
(602) 747-4197
Signed By Date
1/15/2016
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