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SAFEWAY INC
CAH501333-00 KITTITAS COUNTY PUBLIC HOSPITAL DISTRICT #1
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Covered Entity Details
Entity Name
KITTITAS COUNTY PUBLIC HOSPITAL DISTRICT #1
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH501333-00
Entity Address
603 S CHESTNUT ST
ELLENSBURG, WA 98926
Medicare Provider Number
501333
Participating Start Date
8/25/2010
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1630
400 N RUBY ST
ELLENSBURG, WA 98926
Pharmacy Comments
Contract Details
Approval Date
12/28/2011
Contract Begin Date
12/28/2011
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
PAUL NURICK, CEO
(509) 962-7301
Contract Pharmacy Representative
SAFEWAY PHARMACY
Merle Jarvill, Director of Manages Care
(623) 869-4260
Signed By Date
12/5/2011
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