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SAFEWAY INC
DSH050174 ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital
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Covered Entity Details
Entity Name
ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050174
Entity Address
1165 MONTGOMERY DRIVE
Santa Rosa, CA 95405
Medicare Provider Number
050174
Participating Start Date
4/1/2015
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1434
9080 BROOKS RD S
WINDSOR, CA 95492-7811
Pharmacy Comments
04/18/2012 updated address (was 9080 BROOKS ROAD SOUTH)
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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