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BANNER FAMILY PHARMACY - GATEWAY
DSH030122 BANNER GATEWAY MEDICAL CENTER
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Covered Entity Details
Entity Name
BANNER GATEWAY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030122
Entity Address
1900 NORTH HIGLEY ROAD
GILBERT, AZ 85234
Medicare Provider Number
030122
Participating Start Date
10/1/2015
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
BANNER FAMILY PHARMACY - GATEWAY
Pharmacy Address
1900 N HIGLEY RD
GILBERT, AZ 85234
Pharmacy Comments
Contract Details
Approval Date
7/13/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Leslie Flake, Chief Financial Officer
(602) 747-3950
Contract Pharmacy Representative
Banner Health
Russell Funk, CEO Banner Pharmacy Services
(602) 747-4197
Signed By Date
7/13/2015
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