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SAFEWAY INC
CAH061321-00 Trinidad Area Health Association DBA Mount San Rafael Hospital
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Covered Entity Details
Entity Name
Trinidad Area Health Association DBA Mount San Rafael Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH061321-00
Entity Address
410 Benedicta Avenue
Trinidad, CO 81082-2005
Medicare Provider Number
061321
Participating Start Date
7/1/2012
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #0722
457 W MAIN ST
TRINIDAD, CO 81082
Pharmacy Comments
Contract Details
Approval Date
7/13/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/3/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
DAVID ROLLINS, CFO
(719) 846-8042
Contract Pharmacy Representative
Chuck Hanson, 340B Program Manager
(208) 395-6304
Signed By Date
7/13/2016
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