Contract Pharmacy Details

SAFEWAY INC
DSH380017 LEGACY GOOD SAMARITAN HOSPITAL

Covered Entity Details

Entity Name

LEGACY GOOD SAMARITAN HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH380017

Entity Address

1015 NW 22ND AVENUE
PORTLAND, OR 97210

Medicare Provider Number

380017

Participating Start Date

10/1/2016

Last Recertification Date

9/2/2024

Pharmacy Details

Pharmacy Name

SAFEWAY INC

Pharmacy Address

SAFEWAY PHARMACY #2790
1303 NW LOVEJOY ST
PORTLAND, OR 97209

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