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SAFEWAY INC
CAH051321-00 NorCal HealthConnect LLC- DBA Healdsburg Hospital
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Covered Entity Details
Entity Name
NorCal HealthConnect LLC- DBA Healdsburg Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH051321-00
Entity Address
1375 UNIVERSITY AVENUE
HEALDSBURG, CA 95448
Medicare Provider Number
051321
Participating Start Date
8/23/2010
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1434
9080 BROOKS RD S
WINDSOR, CA 95492-7811
Pharmacy Comments
04/18/2012 updated address (was 9080 BROOKS ROAD SOUTH)
Contract Details
Approval Date
3/7/2012
Contract Begin Date
3/7/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/27/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Evan Rayner, CEO
(707) 431-6501
Contract Pharmacy Representative
Safeway
Merle Jarvill, Director, Managed Care
(623) 869-4260
Signed By Date
1/11/2012
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