Contract Pharmacy Details

ALBERTSONS LLC
DSH380075 PROVIDENCE MEDFORD MEDICAL CENTER

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

ALBERTSONS LLC

Pharmacy Address

SAV-ON PHARMACY #3595
1360 PLAZA BLVD
CENTRAL POINT, OR 97502

Pharmacy Comments

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

340B Drug Pricing Program Database