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SAFEWAY INC
CAH031318-00 BANNER PAYSON MEDICAL CENTER
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Covered Entity Details
Entity Name
BANNER PAYSON MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031318-00
Entity Address
807 S. PONDEROSA
PAYSON, AZ 85541
Medicare Provider Number
031318
Participating Start Date
1/1/2020
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1536
401 EAST HIGHWAY260
PAYSON, AZ 85541
Pharmacy Comments
Contract Details
Approval Date
1/9/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/27/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Matthew K King, Senior Finance Director
(801) 682-9661
Contract Pharmacy Representative
SAFEWAY
Charles Hanson, 340B Program Manager
(208) 395-6304
Signed By Date
1/9/2020
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