Contract Pharmacy Details

SAFEWAY INC
RRC380014-00 GOOD SAMARITAN HOSPITAL CORVALLIS

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 #4333
450 SW 3RD ST
CORVALLIS, OR 97333

Pharmacy Comments

11/18/10 UPDATED (WAS ZIP: 97339);

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

340B Drug Pricing Program Database