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SAFEWAY INC
DSH060126 Banner Fort Collins Medical Center
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Covered Entity Details
Entity Name
Banner Fort Collins Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060126
Entity Address
4700 Lady Moon Drive
Fort Collins, CO 80528
Medicare Provider Number
060126
Participating Start Date
10/1/2016
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1791
1535 MAIN ST
WINDSOR, CO 80550
Pharmacy Comments
Contract Details
Approval Date
1/10/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/6/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Krista Touros, CFO - Western Division
(970) 810-1567
Contract Pharmacy Representative
SAFEWAY
Charles Hanson, 340B Program Manager
(208) 395-6304
Signed By Date
1/10/2019
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