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RALPHS GROCERY CO
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
RALPHS GROCERY CO
Pharmacy Address
DBA RALPHS #54
101 OLD GROVE RD
OCEANSIDE, CA 92057
Pharmacy Comments
Contract Details
Approval Date
7/8/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/10/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kevin Mattson, President & CEO
(619) 662-6322
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
7/8/2013
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