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SAFEWAY INC
DSH430048 SPEARFISH REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
SPEARFISH REGIONAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH430048
Entity Address
1440 NORTH MAIN
SPEARFISH, SD 57783
Medicare Provider Number
430048
Participating Start Date
4/1/2019
Last Recertification Date
8/22/2019
Entity Termination Date
3/31/2020
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #0583
1606 NORTH AVE STE 2
SPEARFISH, SD 57783
Pharmacy Comments
Contract Details
Approval Date
1/20/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/3/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Thomas Worsley, President
(605) 644-4091
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
1/15/2019
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