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LPCH CHILDREN'S HOME PHARMACY
DSH050441 STANFORD HEALTH CARE
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Covered Entity Details
Entity Name
STANFORD HEALTH CARE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050441
Entity Address
300 PASTEUR DRIVE
Stanford, CA 94305
Medicare Provider Number
050441
Participating Start Date
7/1/2015
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
LPCH CHILDREN'S HOME PHARMACY
Pharmacy Address
4200 BOHANNON DR STE 110
MENLO PARK, CA 94025
Pharmacy Comments
Contract Details
Approval Date
7/19/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David Connor, CFO
(650) 725-1074
Contract Pharmacy Representative
Fred Nishioka, Director of Pharmacy
(650) 497-8781
Signed By Date
7/19/2017
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