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GRANE SUPPLY D/B/A GRANE RX
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
GRANE SUPPLY D/B/A GRANE RX
Pharmacy Address
3251 REVERE ST STE 205
AURORA, CO 80011-1847
Pharmacy Comments
Contract Details
Approval Date
10/15/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kevin Mattson, President & CEO
(619) 662-6322
Contract Pharmacy Representative
Grane Rx
Robert Funderlich, Chief Financial Officer
(412) 449-0680
Signed By Date
10/15/2021
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