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SAFEWAY INC
CAH061300-00 Kiowa County Hospital District DBA Weisbrod Memorial Hospital
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Covered Entity Details
Entity Name
Kiowa County Hospital District DBA Weisbrod Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH061300-00
Entity Address
1208 Luther Street
Eads, CO 81036
Medicare Provider Number
061300
Participating Start Date
10/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1721
906 E. OLIVE STREET
LAMAR, CO 81052
Pharmacy Comments
Contract Details
Approval Date
10/11/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/27/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tristen Sheridan, CEO
(719) 438-5401
Contract Pharmacy Representative
Tristen Sheridan, CEO
(719) 438-5401
Signed By Date
10/11/2013
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