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SAFEWAY INC
DSH060004 Brighton Community Hospital Association DBA: Intermountain Health Platte Valley Hospital
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Covered Entity Details
Entity Name
Brighton Community Hospital Association DBA: Intermountain Health Platte Valley Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060004
Entity Address
1600 PRAIRIE CENTER PKWY.
BRIGHTON, CO 80601
Medicare Provider Number
060004
Participating Start Date
4/1/2006
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1045
1300 DEXTER STREET
FORT LUPTON, CO 80621
Pharmacy Comments
Contract Details
Approval Date
1/15/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/31/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JOHN HICKS, PRESIDENT
(303) 498-1601
Contract Pharmacy Representative
Safeway
Thuy Le, 340B Program Manager
(925) 467-2825
Signed By Date
1/15/2014
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