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SAN MATEO NEIGHBORHOOD PHARMACY
DSH050113A SAN MATEO MEDICAL CENTER
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Covered Entity Details
Entity Name
SAN MATEO MEDICAL CENTER
Subdivision Name
SAN MATEO COUNTY MEDICAL CENTER / Mobile Clinic
Type
Disproportionate Share Hospital
340B ID
DSH050113A
Entity Address
222 W 39TH AVE
SAN MATEO, CA 94403
Medicare Provider Number
050113
Outpatient Facility Provider Number
Participating Start Date
7/1/2015
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
SAN MATEO NEIGHBORHOOD PHARMACY
Pharmacy Address
9 37TH AVENUE
SAN MATEO, CA 94403
Pharmacy Comments
Contract Details
Approval Date
7/15/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/1/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
CHESTER J. KUNNAPPILLY, CEO
(650) 573-2305
Contract Pharmacy Representative
Alvin Lee, Owner
(650) 827-5277
Signed By Date
7/15/2016
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