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TED'S VILLAGE PHARMACY INC
DSH050113 SAN MATEO MEDICAL CENTER
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Covered Entity Details
Entity Name
SAN MATEO MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050113
Entity Address
222 WEST 39TH AVENUE
SAN MATEO, CA 94403
Medicare Provider Number
050113
Participating Start Date
1/1/2005
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
TED'S VILLAGE PHARMACY INC
Pharmacy Address
29 W 25TH AVE
SAN MATEO, CA 94403-2236
Pharmacy Comments
Contract Details
Approval Date
4/22/2010
Contract Begin Date
5/1/2010
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/3/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
4/12/2010
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