Contract Pharmacy Details

SAFEWAY INC
SCH380001-03 MID-COLUMBIA MEDICAL CENTER

Covered Entity Details

Entity Name

MID-COLUMBIA MEDICAL CENTER

Subdivision Name

MID-COLUMBIA MEDICAL CENTER-INTERNAL MEDICINE RURAL HEALTH CLINIC

Type

Sole Community Hospital

340B ID

SCH380001-03

Entity Address

1815 E 19TH STREET
THE DALLES, OR 97058

Medicare Provider Number

380001

Outpatient Facility Provider Number

383997

Participating Start Date

9/28/2010

Last Recertification Date

8/30/2016

Entity Termination Date

4/1/2017

Pharmacy Details

Pharmacy Name

SAFEWAY INC

Pharmacy Address

SAFEWAY PHARMACY #1489
520 MT HOOD ST
THE DALLES, OR 97058-3555

Pharmacy Comments

Contract Details

Approval Date

7/2/2012

Contract Begin Date

7/2/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2017

Contacts

Covered Entity Signing Official

DONALD ARBON, V.P. FINANCE/CFO
(541) 296-7524

Contract Pharmacy Representative

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

Signed By Date

5/30/2012

340B Drug Pricing Program Database