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SAFEWAY INC
DSH030016 Banner Casa Grande Medical Center
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Covered Entity Details
Entity Name
Banner Casa Grande Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030016
Entity Address
1800 East Florence Blvd.
Casa Grande, AZ 85122
Medicare Provider Number
030016
Participating Start Date
10/1/2013
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1706
1637 N TREKELL RD
CASA GRANDE, AZ 85122
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
6/16/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeff Allen Buehrle, CFO
(480) 394-4396
Contract Pharmacy Representative
SAFEWAY
Charles Hanson, 340B Program Manager
(208) 395-6304
Signed By Date
10/15/2018
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