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SAFEWAY INC
DSH380029 SILVERTON HEALTH DBA LEGACY SILVERTON MEDICAL CENTER OR SILVERTON HEALTH
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Covered Entity Details
Entity Name
SILVERTON HEALTH DBA LEGACY SILVERTON MEDICAL CENTER OR SILVERTON HEALTH
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380029
Entity Address
342 FAIRVIEW STREET
SILVERTON, OR 97381-1993
Medicare Provider Number
380029
Participating Start Date
1/1/2019
Last Recertification Date
9/2/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1976
1550 N. PACIFIC HWY
WOODBURN, OR 97071
Pharmacy Comments
Contract Details
Approval Date
10/11/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2016
Contacts
Covered Entity Signing Official
Daniel L. Jessup, CHIEF FINANCIAL OFFICER
(503) 873-1548
Contract Pharmacy Representative
Thuy Lee, 340B Program Manager
(925) 467-2825
Signed By Date
10/11/2013
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