Contract Pharmacy Details

SAFEWAY INC
CH09289B NORTH COUNTRY HEALTHCARE, INC.

Covered Entity Details

Entity Name

NORTH COUNTRY HEALTHCARE, INC.

Subdivision Name

NORTH COUNTRY - ASH FORK SITE

Type

HRSA-Funded Health Center

340B ID

CH09289B

Entity Address

112 PARK AVENUE
ASH FORK, AZ 86320-0000

Grant Number

H80CS00651

Participating Start Date

7/1/2002

Last Recertification Date

1/29/2020

Entity Termination Date

1/1/2021

Pharmacy Details

Pharmacy Name

SAFEWAY INC

Pharmacy Address

SAFEWAY PHARMACY #1639
637 W ROUTE 66
WILLIAMS, AZ 86046

Pharmacy Comments

Contract Details

Approval Date

4/5/2011

Contract Begin Date

4/5/2011

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/1/2021
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Contract Pharmacy Representative

Signed By Date

3/11/2011

340B Drug Pricing Program Database