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SAFEWAY PHARMACY #4520
DSH500050 PeaceHealth Southwest Medical Center
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Covered Entity Details
Entity Name
PeaceHealth Southwest Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500050
Entity Address
400 NE Mother Joseph Place
VANCOUVER, WA 98664
Medicare Provider Number
500050
Participating Start Date
4/1/2005
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
SAFEWAY PHARMACY #4520
Pharmacy Address
11696 NE 76TH
VANCOUVER, WA 98662
Pharmacy Comments
Contract Details
Approval Date
4/26/2012
Contract Begin Date
4/26/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/4/2016
Pharmacy closed
Contacts
Covered Entity Signing Official
Joe Ness, VP of Ancillary and Support Services
(360) 514-2275
Contract Pharmacy Representative
Safeway
Merle Jarvill, Director, Managed Care
(623) 869-4260
Signed By Date
4/2/2012
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