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SAFEWAY INC
CAH031304-00 Page Hospital
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Covered Entity Details
Entity Name
Page Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031304-00
Entity Address
501 North Navajo
Page, AZ 86040
Medicare Provider Number
031304
Participating Start Date
4/1/2012
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #0249
P.O.BOX 1346
650 ELM STREET
PAGE, AZ 86040
Pharmacy Comments
Contract Details
Approval Date
2/27/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/15/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Dave Kaubisch, Vice President of Finance
(602) 747-4556
Contract Pharmacy Representative
SAFEWAY PHARMACY
Merle Jarvill, Director of Manages Care
(623) 869-4260
Signed By Date
1/11/2013
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