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WALGREEN CO.
DSH050026 GROSSMONT HOSPITAL
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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 #12387
1306 BROADWAY
EL CAJON, CA 92021
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
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