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SAFEWAY INC
DSH380075 PROVIDENCE MEDFORD MEDICAL CENTER
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Covered Entity Details
Entity Name
PROVIDENCE MEDFORD MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380075
Entity Address
1111 CRATER LAKE AVENUE
MEDFORD, OR 97504
Medicare Provider Number
380075
Participating Start Date
7/1/2015
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1643
3169 CRATER LAKE HIWAY
MEDFORD, OR 97504
Pharmacy Comments
10/27/2011 updated zip from 97501 (EMG)
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Christopher Pizzi, Chief Operating Officer
(541) 732-5195
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
7/15/2020
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