Contract Pharmacy Details

SAFEWAY INC
DSH380007 LEGACY EMANUEL HOSPITAL & HEALTH CENTER

Covered Entity Details

Entity Name

LEGACY EMANUEL HOSPITAL & HEALTH CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH380007

Entity Address

2801 N GANTENBEIN AVE
PORTLAND, OR 97227

Medicare Provider Number

380007

Participating Start Date

7/1/2007

Last Recertification Date

9/2/2024

Pharmacy Details

Pharmacy Name

SAFEWAY INC

Pharmacy Address

SAFEWAY PHARMACY #1612
1100 NE BROADWAY ST
PORTLAND, OR 97232

Pharmacy Comments

Contract Details

Approval Date

5/3/2023

Contract Begin Date

7/1/2023

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

8/17/2024
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Majid Tanas, VP Pharmacy Services
(503) 415-5011

Contract Pharmacy Representative

Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304

Signed By Date

5/3/2023

340B Drug Pricing Program Database