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SAFEWAY PHARMACY #0320
DSH060001 Banner North Colorado Medical Center
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Covered Entity Details
Entity Name
Banner North Colorado Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060001
Entity Address
1801 16th Street
Greeley, CO 80631
Medicare Provider Number
060001
Participating Start Date
10/1/2013
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
SAFEWAY PHARMACY #0320
Pharmacy Address
1122 11TH AVENUE
GREELEY, CO 80631
Pharmacy Comments
Contract Details
Approval Date
10/16/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/18/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mary McCabe, CFO- Western Region
(970) 810-1566
Contract Pharmacy Representative
Safeway
Thuy Le, 340B Program Manager
(925) 467-2825
Signed By Date
10/16/2013
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