Contract Pharmacy Details

SAFEWAY INC
CAH381317-00 NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER

Covered Entity Details

Entity Name

NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH381317-00

Entity Address

1000 3RD STREET
TILLAMOOK, OR 97141

Medicare Provider Number

381317

Participating Start Date

9/30/2010

Last Recertification Date

8/29/2024

Pharmacy Details

Pharmacy Name

SAFEWAY INC

Pharmacy Address

SAFEWAY PHARMACY #2723
1815 4TH STREET
TILLAMOOK, OR 97141

Pharmacy Comments

Contract Details

Approval Date

8/20/2012

Contract Begin Date

8/20/2012

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

WALTER LARSON, CFO
(503) 815-2260

Contract Pharmacy Representative

Safeway
Merle Jarvill, Director, Managed Care
(623) 869-4260

Signed By Date

7/17/2012

340B Drug Pricing Program Database