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MARINER ADVANCED PHARMACY CORP
DSH050113 SAN MATEO MEDICAL CENTER
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Covered Entity Details
Entity Name
SAN MATEO MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050113
Entity Address
222 WEST 39TH AVENUE
SAN MATEO, CA 94403
Medicare Provider Number
050113
Participating Start Date
1/1/2005
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
MARINER ADVANCED PHARMACY CORP
Pharmacy Address
43 E 3RD AVE
SAN MATEO, CA 94401
Pharmacy Comments
Contract Details
Approval Date
10/5/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/30/2025
Pharmacy closed
Contacts
Covered Entity Signing Official
CHESTER J. KUNNAPPILLY, CEO
(650) 573-2305
Contract Pharmacy Representative
Mariner Advanced Pharmacy
Henry Truong, Pharmacy Director
(650) 579-5678
Signed By Date
10/5/2019
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