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SAFEWAY INC
DSH050113 SAN MATEO MEDICAL CENTER
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Covered Entity Details
Entity Name
SAN MATEO MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050113
Entity Address
222 WEST 39TH AVENUE
SAN MATEO, CA 94403
Medicare Provider Number
050113
Participating Start Date
1/1/2005
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #0747
850 WOODSIDE ROAD
REDWOOD CITY, CA 94061
Pharmacy Comments
Contract Details
Approval Date
4/15/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
SUSAN EHRLICH, CEO
(650) 573-2041
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
4/15/2015
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