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SAFEWAY INC
CAH291313-00 Banner Churchill Community Hospital
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Covered Entity Details
Entity Name
Banner Churchill Community Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH291313-00
Entity Address
801 East Williams Avenue
Fallon, NV 89406
Medicare Provider Number
291313
Participating Start Date
7/1/2016
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1517
890 W WILLIAMS
FALLON, NV 89406
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/6/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Steven Fraker, Chief Financial Officer
(775) 867-7002
Contract Pharmacy Representative
SAFEWAY
Charles Hanson, 340B Program Manager
(208) 395-6304
Signed By Date
10/15/2018
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