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CORAM ALTERNATE SITE SERVICES, INC
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
CORAM ALTERNATE SITE SERVICES, INC
Pharmacy Address
DBA CORAM CVS/SPECIALTY INFUSION SERVICE
12310 WORLD TRADE DRIVE
SUITE 100
SAN DIEGO, CA 92128
Pharmacy Comments
Contract Details
Approval Date
7/14/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/24/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Daniel Kindron, CFO
(619) 740-4743
Contract Pharmacy Representative
Myone Fernandez, Branch Manager
(858) 576-6969
Signed By Date
7/14/2017
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