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ALBERTSON'S LLC
DSH500139 CAPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
CAPITAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500139
Entity Address
3900 CAPITAL MALL DRIVE SW
OLYMPIA, WA 98502
Medicare Provider Number
500139
Participating Start Date
7/1/2022
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
ALBERTSON'S LLC
Pharmacy Address
SAFEWAY PHARMACY #1407
705 TROSPER ROAD S.W.
TUMWATER, WA 98512
Pharmacy Comments
Contract Details
Approval Date
4/12/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/11/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Timothy Wayne Lynch, Sr. VP, Chief Administrative Officer
(253) 403-2824
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
4/12/2023
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