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WESTERN PHARMACY GROUP LLC
CH091080 SAN YSIDRO HEALTH CENTER
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Covered Entity Details
Entity Name
SAN YSIDRO HEALTH CENTER
Subdivision Name
San Ysidro Health San Ysidro Health Center
Type
HRSA-Funded Health Center
340B ID
CH091080
Entity Address
4004 BEYER BLVD
San Ysidro, CA 92173
Grant Number
H80CS10748
Participating Start Date
12/1/1992
Last Recertification Date
3/4/2025
Pharmacy Details
Pharmacy Name
WESTERN PHARMACY GROUP LLC
Pharmacy Address
DBA MEDICAL CENTER PHARMACY
340 4TH AVE STE 1
CHULA VISTA, CA 91910-3882
Pharmacy Comments
Contract Details
Approval Date
4/10/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/3/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kevin Mattson, President & CEO
(619) 662-6322
Contract Pharmacy Representative
Community Medical Center Pharmacy
Michelle Darnelle, Operations / Business Development Manager
(619) 206-0117
Signed By Date
4/10/2018
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