Contract Pharmacy Details

WALGREEN CO.
DSH050026 GROSSMONT HOSPITAL

Covered Entity Details

Entity Name

GROSSMONT HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH050026

Entity Address

5555 GROSSMONT CENTER DRIVE
LA MESA, CA 91942

Medicare Provider Number

050026

Participating Start Date

7/1/2004

Last Recertification Date

9/3/2024

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS #11406
10512 MISSION GORGE RD
SANTEE, CA 92071-3146

Pharmacy Comments

Contract Details

Approval Date

10/17/2016

Contract Begin Date

1/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/1/2017
Pharmacy closed

Contacts

Covered Entity Signing Official

Daniel Kindron, CFO
(619) 740-4743

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

10/17/2016

340B Drug Pricing Program Database