Contract Pharmacy Details

ALBERTSONS LLC
DSH380052 SAINT ALPHONSUS MEDICAL CENTER - ONTARIO INC.

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

ALBERTSONS LLC

Pharmacy Address

SAV-ON PHARMACY #168
405 S MAIN ST
PAYETTE, ID 83661

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

4/1/2019
Covered Entity Terminated

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

340B Drug Pricing Program Database