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SAFEWAY INC
DSH380025 LEGACY MOUNT HOOD MEDICAL CENTER
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Covered Entity Details
Entity Name
LEGACY MOUNT HOOD MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380025
Entity Address
24800 SE STARK ST
GRESHAM, OR 97030
Medicare Provider Number
380025
Participating Start Date
7/1/2007
Last Recertification Date
9/2/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1542
2501 SW CHERRY PARK ROAD
TROUTDALE, OR 97060
Pharmacy Comments
Contract Details
Approval Date
4/4/2012
Contract Begin Date
4/4/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/16/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
David E. Eager, Sr. VP and CFO, Legacy Health
(503) 415-5730
Contract Pharmacy Representative
Safeway
Merle Jarvill, Director, Managed Care
(623) 869-4260
Signed By Date
2/29/2012
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