Provider Demographics
NPI:1457330300
Name:GROSSMONT HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:GROSSMONT HOSPITAL CORPORATION
Other - Org Name:SHARP HOME INFUSION SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-740-4648
Mailing Address - Street 1:3558 RUFFIN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2596
Mailing Address - Country:US
Mailing Address - Phone:858-627-5600
Mailing Address - Fax:858-627-5610
Practice Address - Street 1:3558 RUFFIN RD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2596
Practice Address - Country:US
Practice Address - Phone:858-627-5600
Practice Address - Fax:858-627-5610
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GROSSMONT HOSPITAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-10
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BP3500X, 333600000X
CAPHY438653336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA392720Medicaid
2114095OtherPK
0696050001Medicare NSC