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CHULAVISTA PHARMACY LLC
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
CHULAVISTA PHARMACY LLC
Pharmacy Address
384 H ST # 100
CHULA VISTA, CA 91910-5513
Pharmacy Comments
Contract Details
Approval Date
4/14/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kevin Mattson, President & CEO
(619) 662-6322
Contract Pharmacy Representative
Elvis Atencio, Pharmacist In Charge
(619) 781-8177
Signed By Date
4/14/2017
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