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SAFEWAY INC
CAH381301-00 COTTAGE GROVE COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
COTTAGE GROVE COMMUNITY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH381301-00
Entity Address
1515 VILLAGE DRIVE
COTTAGE GROVE, OR 97424-9700
Medicare Provider Number
381301
Participating Start Date
4/1/2017
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1458
1500 E MAIN ST
COTTAGE GROVE, OR 97424
Pharmacy Comments
Contract Details
Approval Date
7/19/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/5/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tim Herrmann, VP Patient Care Services
(541) 767-5201
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
7/19/2019
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