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SAFEWAY INC
DSH380056 SANTIAM MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
SANTIAM MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380056
Entity Address
1401 NORTH 10TH AVE
STAYTON, OR 97383
Medicare Provider Number
380056
Participating Start Date
7/1/2021
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1527
1535 N FIRST AVE
STAYTON, OR 97383-1213
Pharmacy Comments
Contract Details
Approval Date
4/13/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Maggie Ann Hudson, CEO
(503) 769-9236
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
4/13/2020
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