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SAFEWAY INC
CAH031312-00 Bisbee Hospital Association dba Copper Queen Community Hospital
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Covered Entity Details
Entity Name
Bisbee Hospital Association dba Copper Queen Community Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031312-00
Entity Address
101 Cole Ave
Bisbee, AZ 85603
Medicare Provider Number
031312
Participating Start Date
4/1/2013
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #0261
101 NACO HIGHWAY
BOX 101
BISBEE, AZ 85603
Pharmacy Comments
Contract Details
Approval Date
4/25/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Diane Moore, CFO
(520) 432-6450
Contract Pharmacy Representative
Safeway
Merle Jarvill, Director, Managed Care
(623) 869-4260
Signed By Date
4/25/2013
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