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SAFEWAY INC
CAH031304-00 Page Hospital
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Covered Entity Details
Entity Name
Page Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031304-00
Entity Address
501 North Navajo
Page, AZ 86040
Medicare Provider Number
031304
Participating Start Date
4/1/2012
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #0249
P.O.BOX 1346
650 ELM STREET
PAGE, AZ 86040
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
7/5/2020
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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