Healthcare Provider Details

I. General information

NPI: 1801256789
Provider Name (Legal Business Name): GROSSMONT HOSPITAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2016
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 GROSSMONT CENTER DR # A217
LA MESA CA
91942-3019
US

IV. Provider business mailing address

5555 GROSSMONT CENTER DR A217
LA MESA CA
91942-3019
US

V. Phone/Fax

Practice location:
  • Phone: 619-740-4458
  • Fax: 619-740-4266
Mailing address:
  • Phone: 619-740-4458
  • Fax: 619-740-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number53675
License Number StateCA

VIII. Authorized Official

Name: SCOTT EVANS
Title or Position: CEO
Credential:
Phone: 619-740-4648