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WALGREEN ARIZONA DRUG CO.
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
WALGREEN ARIZONA DRUG CO.
Pharmacy Address
DBA: WALGREENS # 06177
1135 N MESA DRIVE
MESA, AZ 85201
Pharmacy Comments
Contract Details
Approval Date
7/15/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Thomas M. Matenaer, Chief Financial Officer
(480) 543-2295
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/15/2016
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