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SAFEWAY INC
SCH380001-04 Mid-Columbia Medical Center DBA Adventist Health Columbia Gorge
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Covered Entity Details
Entity Name
Mid-Columbia Medical Center DBA Adventist Health Columbia Gorge
Subdivision Name
MCMC FAMILY MEDICINE - RURAL HEALTH CLINIC
Type
Sole Community Hospital
340B ID
SCH380001-04
Entity Address
1620 E 12TH STREET
THE DALLES, OR 97058
Medicare Provider Number
380001
Outpatient Facility Provider Number
383996
Participating Start Date
9/28/2010
Last Recertification Date
8/23/2024
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
1/8/2021
Agreement registered in error
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
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