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SAFEWAY INC
CAH131328-00 Bonner General Hospital
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Covered Entity Details
Entity Name
Bonner General Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131328-00
Entity Address
520 North 3rd Avenue
Sandpoint, ID 83864
Medicare Provider Number
131328
Participating Start Date
4/1/2014
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #0350
702 N. 5TH AVENUE
SANDPOINT, ID 83864
Pharmacy Comments
Contract Details
Approval Date
7/27/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/1/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Sheryl Rickard, Chief Executive Officer
(208) 263-1441 Ext: 1100
Contract Pharmacy Representative
Ronald Richmond, Group Director of Managed Care
(630) 948-8988
Signed By Date
7/27/2017
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