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SAFEWAY INC
CAH281356-00 PERKINS COUNTY HEALTH SERVICES
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Covered Entity Details
Entity Name
PERKINS COUNTY HEALTH SERVICES
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH281356-00
Entity Address
900 Lincoln Avenue
GRANT, NE 69140
Medicare Provider Number
281356
Participating Start Date
10/1/2015
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
SAFEWAY INC
Pharmacy Address
SAFEWAY PHARMACY #0557
611 NORTH SPRUCE STREET
OGALLALA, NE 69153
Pharmacy Comments
Contract Details
Approval Date
4/5/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Derick Lorentz, CFO
(308) 352-7228
Contract Pharmacy Representative
Albertsons
Ronald Richmon, Group Director of Managed Care
(630) 948-6285
Signed By Date
4/5/2017
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