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MEDICAL CENTER PHARMACY LTC
DSH050077 SCRIPPS MERCY HOSPITAL
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Covered Entity Details
Entity Name
SCRIPPS MERCY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050077
Entity Address
4077 FIFTH AVENUE
SAN DIEGO, CA 92103
Medicare Provider Number
050077
Participating Start Date
1/1/2005
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
MEDICAL CENTER PHARMACY LTC
Pharmacy Address
CONDUCTED BY WESTERN PHARMACY GROUP LLC
610 GATEWAY CENTER WAY STE H-I
SAN DIEGO, CA 92102-4533
Pharmacy Comments
Contract Details
Approval Date
4/21/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/7/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tom Gammiere, CEO
(619) 260-7101
Contract Pharmacy Representative
Community Medical Center Pharmacy
Michelle Darnelle, Operations / Business Development Manager
(619) 206-0117
Signed By Date
4/21/2020
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