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SAFEWAY INC
DSH060012 St. Mary-Corwin Hospital
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Covered Entity Details
Entity Name
St. Mary-Corwin Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060012
Entity Address
1008 Minnequa Avenue
Pueblo, CO 81004
Medicare Provider Number
060012
Participating Start Date
4/1/2014
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #3729
1231 SOUTH PRAIRIE AVENUE
PUEBLO, CO 81005
Pharmacy Comments
Contract Details
Approval Date
7/23/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/27/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Vanessa Kochevar, Chief Financial Officer
(719) 557-4668
Contract Pharmacy Representative
Syed Hashmi, 340B Program Manager
(925) 467-2807
Signed By Date
7/23/2015
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