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SAFEWAY INC
DSH380022 SAMARITAN ALBANY GENERAL HOSPITAL
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Covered Entity Details
Entity Name
SAMARITAN ALBANY GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380022
Entity Address
1046 6TH AVE SW
ALBANY, OR 97321
Medicare Provider Number
380022
Participating Start Date
4/1/2012
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1659
1990 14TH AVE, S.E.
ALBANY, OR 97322
Pharmacy Comments
06/18/2012 Change zip (was 97322); 10/28/2011 Changed zip (was 97321)
Contract Details
Approval Date
6/20/2012
Contract Begin Date
6/20/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/9/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Daniel Smith, VP Finance/CFO
(541) 768-5390
Contract Pharmacy Representative
Safeway
charles Hanson, 340B program manager
(208) 395-6304
Signed By Date
5/23/2012
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