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SAFEWAY INC
CH09289I NORTH COUNTRY HEALTHCARE, INC.
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Covered Entity Details
Entity Name
NORTH COUNTRY HEALTHCARE, INC.
Subdivision Name
NORTH COUNTRY CHC-SELIGMAN SITE
Type
HRSA-Funded Health Center
340B ID
CH09289I
Entity Address
22585 W. OAK STREET
SELIGMAN, AZ 86337-0776
Grant Number
H80CS00651
Participating Start Date
7/1/2010
Last Recertification Date
2/15/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1639
637 W ROUTE 66
WILLIAMS, AZ 86046
Pharmacy Comments
Contract Details
Approval Date
12/13/2010
Contract Begin Date
12/13/2010
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
ANN ROGGENBUCK, CEO
(928) 213-6100 Ext: 2300
Contract Pharmacy Representative
Safeway
Merle Jarvill, Director, Managed Care
(623) 869-4260
Signed By Date
11/29/2010
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