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CORAM ALTERNATE SITE SERVICES, INC.
DSH030002 Banner – University Medical Center Phoenix
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Covered Entity Details
Entity Name
Banner – University Medical Center Phoenix
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030002
Entity Address
1111 EAST MCDOWELL ROAD
PHOENIX, AZ 85006
Medicare Provider Number
030002
Participating Start Date
9/9/2005
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
CORAM ALTERNATE SITE SERVICES, INC.
Pharmacy Address
DBA CORAM CVS/SPECIALTY INFUSION SERVICE
7400 WASHINGTON STREET NE
ALBUQUERQUE, NM 87109
Pharmacy Comments
Contract Details
Approval Date
1/10/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/22/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Trent S. Blain, Sr Dir Finance
(602) 839-5114
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/10/2018
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