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SAFEWAY INC
CAH061327-00 Southwest Memorial Hospital
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Covered Entity Details
Entity Name
Southwest Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH061327-00
Entity Address
1311 North Mildred
Cortez, CO 81321
Medicare Provider Number
061327
Participating Start Date
4/1/2012
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1892
1580 E. MAIN STREET
CORTEZ, CO 81321
Pharmacy Comments
06/28/2012 changed zip (was 81231)
Contract Details
Approval Date
8/24/2012
Contract Begin Date
8/24/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/31/2017
Agreement registered in error
Contacts
Covered Entity Signing Official
Kent Helwig, CEO
(970) 564-2146
Contract Pharmacy Representative
Safeway
Merle Jarvill, Director, Managed Care
(623) 869-4260
Signed By Date
8/8/2012
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