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SAFEWAY INC
DSH050136 NorCal HealthConnect LLC, DBA Petaluma Valley Hospital
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Covered Entity Details
Entity Name
NorCal HealthConnect LLC, DBA Petaluma Valley Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050136
Entity Address
400 N. MCDOWELL BLVD
PETALUMA, CA 94954
Medicare Provider Number
050136
Participating Start Date
4/1/2015
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #3011
389 S. MCDOWELL BLVD
PETALUMA, CA 94954
Pharmacy Comments
01/03/2012 pharmacy update (was Safeway #0796 373 S. McDowell St.)
Contract Details
Approval Date
7/14/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/19/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mich Riccioni, CFO
(707) 445-8121 Ext: 7491
Contract Pharmacy Representative
Safeway
Thuy Le, 340B Program Manager
(925) 467-2825
Signed By Date
7/14/2015
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