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CYSTIC FIBROSIS SERVICES, LLC
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
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
6/30/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2017
Business decision by covered entity and/or pharmacy
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
6/30/2017
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