Contract Pharmacy Details

SAFEWAY INC
RRC380014-00 GOOD SAMARITAN HOSPITAL CORVALLIS

Covered Entity Details

Entity Name

GOOD SAMARITAN HOSPITAL CORVALLIS

Subdivision Name

Type

Rural Referral Center

340B ID

RRC380014-00

Entity Address

3600 NW SAMARITAN DRIVE
CORVALLIS, OR 97330

Medicare Provider Number

380014

Participating Start Date

10/1/2018

Last Recertification Date

8/23/2024

Pharmacy Details

Pharmacy Name

SAFEWAY INC

Pharmacy Address

SAFEWAY PHARMACY #4333
450 SW 3RD ST
CORVALLIS, OR 97333

Pharmacy Comments

11/18/10 UPDATED (WAS ZIP: 97339);

Contract Details

Approval Date

8/20/2018

Contract Begin Date

10/1/2018

Carve-In Effective Date

Contract Comments

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

8/20/2018

340B Drug Pricing Program Database