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CHILDREN'S HOMECARE PHARMACY
PED053303-00 RADY CHILDREN'S HOSPITAL SAN DIEGO
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Covered Entity Details
Entity Name
RADY CHILDREN'S HOSPITAL SAN DIEGO
Subdivision Name
Type
Children's Hospital
340B ID
PED053303-00
Entity Address
3020 Children's Way
San Diego, CA 92123-4282
Medicare Provider Number
053303
Participating Start Date
1/1/2015
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
CHILDREN'S HOMECARE PHARMACY
Pharmacy Address
RADY CHILDREN'S HOMECARE PHARMACY
8291 AERO PLACE STE 130 140 150
SAN DIEGO, CA 92123
Pharmacy Comments
Contract Details
Approval Date
4/12/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Nicholas Matthew Holmes, Senior VP, Chief Operating Officer
(858) 966-5948
Contract Pharmacy Representative
Rady Children's Hospital San Diego
MICHAEL DWAINE CLARK, PHARMACY MANAGER
(858) 966-4941 Ext: 6917
Signed By Date
4/12/2018
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