Contract Pharmacy Details

MEDICAL CENTER PHARMACY
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

MEDICAL CENTER PHARMACY

Pharmacy Address

3904 PARK BLVD
SAN DIEGO, CA 92103

Pharmacy Comments

Contract Details

Approval Date

6/15/2012

Contract Begin Date

6/15/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2018
Ownership change

Contacts

Covered Entity Signing Official

Tony Weber, CFO
(619) 662-4100

Contract Pharmacy Representative

George Awad, Pharmacy Director
(619) 997-4702

Signed By Date

7/13/2012