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SAFEWAY INC
CAH291300-00 MT. GRANT GENERAL HOSPITAL
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Covered Entity Details
Entity Name
MT. GRANT GENERAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH291300-00
Entity Address
1ST AND A STREETS
HAWTHORNE, NV 89415
Medicare Provider Number
291300
Participating Start Date
1/1/2020
Last Recertification Date
Entity Termination Date
10/1/2020
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #2255
HIGHWAY 95 & ARMORY
HAWTHORNE, NV 89415
Pharmacy Comments
Contract Details
Approval Date
1/4/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Michael Tomislav Metkovich, CFO
(775) 945-2461
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
1/4/2019
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