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SAFEWAY INC
CAH051325-00 ADVENTIST HEALTH MENDOCINO COAST
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Covered Entity Details
Entity Name
ADVENTIST HEALTH MENDOCINO COAST
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH051325-00
Entity Address
700 RIVER DRIVE
FORT BRAGG, CA 95437
Medicare Provider Number
051325
Participating Start Date
8/11/2010
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #0978
660 SOUTH MAIN STREET
FORT BRAGG, CA 95437
Pharmacy Comments
Contract Details
Approval Date
4/14/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/28/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Wayne C. Allen, CEO
(707) 961-4630
Contract Pharmacy Representative
Safeway
Thuy Le, 340B Program Manager
(925) 467-2825
Signed By Date
4/14/2014
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