Contract Pharmacy Details

SAFEWAY INC
DSH380014 GOOD SAMARITAN HOSPITAL CORVALLIS

Covered Entity Details

Entity Name

GOOD SAMARITAN HOSPITAL CORVALLIS

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH380014

Entity Address

3600 NW SAMARITAN DRIVE
CORVALLIS, OR 97330

Medicare Provider Number

380014

Participating Start Date

7/1/2017

Last Recertification Date

11/18/2017

Entity Termination Date

7/1/2018

Pharmacy Details

Pharmacy Name

SAFEWAY INC

Pharmacy Address

SAFEWAY PHARMACY #1765
5270 SW PHILOMATH BLVD.
CORVALLIS, OR 97333

Pharmacy Comments

Contract Details

Approval Date

4/18/2017

Contract Begin Date

7/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2018
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

4/18/2017

340B Drug Pricing Program Database