Provider Demographics
NPI:1760862924
Name:SHARP GROSSMONT HOSPITAL PHARMACY
Entity Type:Organization
Organization Name:SHARP GROSSMONT HOSPITAL PHARMACY
Other - Org Name:COSTCO WHOLESALER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:STAFF PHARMACIST
Authorized Official - Prefix:MS
Authorized Official - First Name:KARLENE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:SARRISIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:619-740-4451
Mailing Address - Street 1:11192 SOCORRO ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-1321
Mailing Address - Country:US
Mailing Address - Phone:858-449-9475
Mailing Address - Fax:619-740-4354
Practice Address - Street 1:5555 GROSSMONT CENTER DR
Practice Address - Street 2:OUTPATIENT PHARMACY
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3019
Practice Address - Country:US
Practice Address - Phone:619-740-4458
Practice Address - Fax:619-740-4354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH38344282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHB374550Medicaid