Contract Pharmacy Details

LONGS DRUG STORES CALIFORNIA, L.L.C.
CH091080 SAN YSIDRO HEALTH CENTER

Covered Entity Details

Entity Name

SAN YSIDRO HEALTH CENTER

Subdivision Name

San Ysidro Health San Ysidro Health Center

Type

HRSA-Funded Health Center

340B ID

CH091080

Entity Address

4004 BEYER BLVD
San Ysidro, CA 92173

Grant Number

H80CS10748

Participating Start Date

12/1/1992

Last Recertification Date

3/4/2025

Pharmacy Details

Pharmacy Name

LONGS DRUG STORES CALIFORNIA, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 09693
1665 E VALLEY PKWY
ESCONDIDO, CA 92027

Pharmacy Comments

Contract Details

Approval Date

10/15/2019

Contract Begin Date

1/1/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/15/2019
Agreement registered in error

Contacts

Covered Entity Signing Official

Kevin Mattson, President & CEO
(619) 662-6322

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

10/15/2019

340B Drug Pricing Program Database