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KMART PHARMACY #4996
DSH030111 Banner – University Medical Center South
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Covered Entity Details
Entity Name
Banner – University Medical Center South
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030111
Entity Address
2800 EAST AJO WAY
TUCSON, AZ 85713
Medicare Provider Number
030111
Participating Start Date
4/1/2006
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 Pharmacy Services
Al Cortese, Sr. Director of Pharmacy
(520) 834-4210
Signed By Date
10/13/2017
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