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SAFEWAY INC
DSH500033 SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
SAMARITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500033
Entity Address
801 E WHEELER ROAD
MOSES LAKE, WA 98837
Medicare Provider Number
500033
Participating Start Date
1/1/2009
Last Recertification Date
8/20/2019
Entity Termination Date
7/1/2020
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #3252
601 S. PIONEER WAY
MOSES LAKE, WA 98837-4801
Pharmacy Comments
08/02/2012 added suite
Contract Details
Approval Date
6/18/2012
Contract Begin Date
6/18/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Thomas J. Legel, CFO
(509) 793-9710
Contract Pharmacy Representative
Merle Jarvill, Director
(623) 869-4260
Signed By Date
6/6/2012
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