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SAFEWAY INC
CAH501323-00 JEFFERSON HEALTHCARE
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Covered Entity Details
Entity Name
JEFFERSON HEALTHCARE
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH501323-00
Entity Address
834 Sheridan St
Port Townsend, WA 98368
Medicare Provider Number
501323
Participating Start Date
1/1/2011
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #0538
442 W SIMS WAY
PORT TOWNSEND, WA 98368
Pharmacy Comments
Contract Details
Approval Date
10/20/2011
Contract Begin Date
10/18/2011
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mike Glenn, Chief Executive Officer
(360) 385-2200 Ext: 2000
Contract Pharmacy Representative
Safeway
Merle Jarvill, Director, Managed Care
(623) 869-4260
Signed By Date
10/5/2011
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