Contract Pharmacy Details

SAFEWAY INC
DSH050296 HAZEL HAWKINS MEMORIAL HOSPITAL

Covered Entity Details

Entity Name

HAZEL HAWKINS MEMORIAL HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH050296

Entity Address

911 SUNSET DRIVE
HOLLISTER, CA 95023

Medicare Provider Number

050296

Participating Start Date

4/1/2018

Last Recertification Date

8/26/2019

Entity Termination Date

10/1/2020

Pharmacy Details

Pharmacy Name

SAFEWAY INC

Pharmacy Address

SAFEWAY PHARMACY #1757
591 TRES PINOS RD.
HOLLISTER, CA 95023

Pharmacy Comments

Contract Details

Approval Date

1/16/2018

Contract Begin Date

4/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/1/2020
Covered Entity Terminated

Contacts

Covered Entity Signing Official

MARK ROBINSON, CFO
(831) 636-2604

Contract Pharmacy Representative

Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304

Signed By Date

1/15/2018

340B Drug Pricing Program Database