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WAL-MART PHARMACY 10-5886
CH091080 SAN YSIDRO HEALTH CENTER
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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
WAL-MART PHARMACY 10-5886
Pharmacy Address
1550 LEUCADIA BLVD
ENCINITAS, CA 92024
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
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/15/2019
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