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KMART PHARMACY #4996
DSH030064 Banner - University Medical Center Tucson
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Covered Entity Details
Entity Name
Banner - University Medical Center Tucson
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030064
Entity Address
1625 North Campbell Avenue
TUCSON, AZ 85719
Medicare Provider Number
030064
Participating Start Date
1/1/1997
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
KMART PHARMACY #4996
Pharmacy Address
7055 EAST BROADWAY
TUCSON, AZ 85710
Pharmacy Comments
Contract Details
Approval Date
10/13/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/19/2018
Agreement registered in error
Contacts
Covered Entity Signing Official
Maurene Polashek, Sr Dir Finance
(520) 694-3446
Contract Pharmacy Representative
Banner University Medical Center Tucson
Kurt Weibel, Director of Pharmacy Services
(520) 694-6061
Signed By Date
10/13/2017
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