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SAFEWAY INC
CAH501308-00 Douglas, Grant, Lincoln, Okanogan Counties Public Hospital District #6
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Covered Entity Details
Entity Name
Douglas, Grant, Lincoln, Okanogan Counties Public Hospital District #6
Subdivision Name
Coulee Medical Center
Type
Critical Access Hospital
340B ID
CAH501308-00
Entity Address
411 Fortuyn Road
Grand Coulee, WA 99133
Medicare Provider Number
501308
Participating Start Date
10/1/2013
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #0385
391 N MAIN ST
COLVILLE, WA 99114
Pharmacy Comments
Contract Details
Approval Date
4/14/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/7/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Alan Wagner, Chief Operating Officer
(509) 633-6362
Contract Pharmacy Representative
Safeway
Thuy Le, 340B Program Manager
(925) 467-2825
Signed By Date
4/14/2014
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