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SAFEWAY INC
DSH050174 ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital
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Covered Entity Details
Entity Name
ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050174
Entity Address
1165 MONTGOMERY DRIVE
Santa Rosa, CA 95405
Medicare Provider Number
050174
Participating Start Date
4/1/2015
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #0933
406 NORTH MAIN STREET
SEBASTOPOL, CA 95472
Pharmacy Comments
Contract Details
Approval Date
1/25/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/29/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Patti Pilgrim, Regional CFO
(707) 525-5323
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
1/25/2021
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