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SAFEWAY INC
CAH031300-00 WICKENBURG COMMUNITY HOSPITAL ASSOCIATION INC
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Covered Entity Details
Entity Name
WICKENBURG COMMUNITY HOSPITAL ASSOCIATION INC
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031300-00
Entity Address
520 ROSE LANE
WICKENBURG, AZ 85390
Medicare Provider Number
031300
Participating Start Date
4/1/2012
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1584
1999 W WICKENBURG WAY
WICKENBURG, AZ 85390
Pharmacy Comments
Contract Details
Approval Date
4/19/2012
Contract Begin Date
4/19/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JIM TAVARY, C.E.O.
(928) 684-4362
Contract Pharmacy Representative
Safeway
Merle Jarvill, Director, Managed Care
(623) 869-4260
Signed By Date
4/6/2012
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