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SAFEWAY INC
CAH031302-00 NORTHERN COCHISE COMMUNITY HOSPITAL, INC.
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Covered Entity Details
Entity Name
NORTHERN COCHISE COMMUNITY HOSPITAL, INC.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031302-00
Entity Address
901 WEST REX ALLEN DRIVE
WILLCOX, AZ 85643
Medicare Provider Number
031302
Participating Start Date
8/5/2010
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #0272
650 N BISBEE AVENUE
WILLCOX, AZ 85643
Pharmacy Comments
Contract Details
Approval Date
1/14/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Roland Knox, CHIEF EXECUTIVE OFFICER
(520) 766-6465
Contract Pharmacy Representative
Safeway
Thuy Le, 340B Program Manager
(925) 467-2825
Signed By Date
1/14/2014
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