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SAFEWAY INC
CAH381323-00 MID-VALLEY HEALTHCARE, INC. DBA SAMARITAN LEBANON COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
MID-VALLEY HEALTHCARE, INC. DBA SAMARITAN LEBANON COMMUNITY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH381323-00
Entity Address
525 N. SANTIAM HWY
LEBANON, OR 97355
Medicare Provider Number
381323
Participating Start Date
8/4/2010
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1659
1990 14TH AVE, S.E.
ALBANY, OR 97322
Pharmacy Comments
06/18/2012 Change zip (was 97322); 10/28/2011 Changed zip (was 97321)
Contract Details
Approval Date
7/17/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/9/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Daniel Smith, VP Finance/CFO
(541) 768-5390
Contract Pharmacy Representative
Safeway
charles Hanson, 340B program manager
(208) 395-6304
Signed By Date
7/17/2018
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