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SAFEWAY INC
CAH051317-00 Adventist Health Clearlake Hospital, Inc.
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Covered Entity Details
Entity Name
Adventist Health Clearlake Hospital, Inc.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH051317-00
Entity Address
15630 18th Ave - Hwy 53
Clearlake, CA 95422
Medicare Provider Number
051317
Participating Start Date
10/1/2011
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #0983
1071 11TH STREET
LAKEPORT, CA 95453
Pharmacy Comments
Contract Details
Approval Date
8/20/2012
Contract Begin Date
8/20/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/24/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Edward McDonald, CFO/COO
(707) 963-6217
Contract Pharmacy Representative
Safeway
Merle Jarvill, Director, Managed Care
(623) 869-4260
Signed By Date
7/17/2012
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