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SAFEWAY INC
DSH380052 SAINT ALPHONSUS MEDICAL CENTER - ONTARIO INC.
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Covered Entity Details
Entity Name
SAINT ALPHONSUS MEDICAL CENTER - ONTARIO INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380052
Entity Address
351 SW 9TH STREET
ONTARIO, OR 97914
Medicare Provider Number
380052
Participating Start Date
7/1/2004
Last Recertification Date
8/30/2018
Entity Termination Date
4/1/2019
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #0371
601 W NORTH ST
ENTERPRISE, OR 97828-1427
Pharmacy Comments
Contract Details
Approval Date
1/16/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/8/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kenneth Fry, VP Finance
(208) 367-3445
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
1/16/2017
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