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SAFEWAY INC
RRC380014-00 GOOD SAMARITAN HOSPITAL CORVALLIS
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Covered Entity Details
Entity Name
GOOD SAMARITAN HOSPITAL CORVALLIS
Subdivision Name
Type
Rural Referral Center
340B ID
RRC380014-00
Entity Address
3600 NW SAMARITAN DRIVE
CORVALLIS, OR 97330
Medicare Provider Number
380014
Participating Start Date
10/1/2018
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #1765
5270 SW PHILOMATH BLVD.
CORVALLIS, OR 97333
Pharmacy Comments
Contract Details
Approval Date
7/18/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2017
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Daniel Smith, VP Finance/CFO
(541) 768-5390
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
7/18/2016
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