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GOLD STALLION, 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
GOLD STALLION, INC
Pharmacy Address
DBA MARINER ADVANCED PHARMACY
345 CONVENTION WAY STE C
REDWOOD CITY, CA 94063
Pharmacy Comments
Contract Details
Approval Date
4/15/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
CHESTER J. KUNNAPPILLY, CEO
(650) 573-2305
Contract Pharmacy Representative
Gold Stallion Inc
Henry Truong, Pharmacy Director
(888) 881-9924
Signed By Date
4/15/2025
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