Covered Entity Details

DSH050025DM UCSD MEDICAL CENTER (Approved) - information as of 4/25/2025 7:30:24 PM

Main Details

Name

UCSD MEDICAL CENTER

Subdivision Name

UCSD Medical Offices North - Gastroenterology Suite

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH050025DM

Medicare Provider Number

050025

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/11/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/17/2025

Last Recertification Date

Contacts

Authorizing Official

UCSD Medical Center
Lori Donaldson, CFO
(619) 543-6613

Primary Contact

UCSD Medical Center
Katrina Tolentino, 340B Program Coordinator
(619) 543-3104

Addresses

Street Address

200 West Arbor Drive
San Diego, CA 92103

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
CA		1184722779

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH050025AA	Child	DSH	UCSD MEDICAL CENTER	UCSD Medical Offices North - Cast Room	200 West Arbor Drive	San Diego	CA	Terminated
DSH050025AB	Child	DSH	UCSD MEDICAL CENTER	UCSD Medical Offices North - Ophthalmology	200 West Arbor Drive	San Diego	CA	Active
DSH050025AC	Child	DSH	UCSD MEDICAL CENTER	Moores Cancer Center Special Procedures	3855 Health Sciences Drive	La Jolla	CA	Active
DSH050025AD	Child	DSH	UCSD MEDICAL CENTER	Moores Cancer Center Infusion	3855 Health Sciences Drive	La Jolla	CA	Active
DSH050025AE	Child	DSH	UCSD MEDICAL CENTER	Moores Cancer Center Clinic	3855 Health Sciences Drive	La Jolla	CA	Active
DSH050025AF	Child	DSH	UCSD MEDICAL CENTER	Sulpizio Cardiovascular Center - Cardiovascular Clinic I	9434 Medical Center Drive	La Jolla	CA	Active
DSH050025AK	Child	DSH	UCSD MEDICAL CENTER	UC San Diego Health System - Encinitas Infusion Center	1200 Garden View Road Ste. 200	Encinitas	CA	Active
DSH050025AL	Child	DSH	UCSD MEDICAL CENTER	UC San Diego Health System - Encinitas Cancer Clinic	1200 Garden View Road Ste. 200	Encinitas	CA	Active
DSH050025AM	Child	DSH	UCSD MEDICAL CENTER	Radiation Oncology PET/CT Center	3960 Health Sciences Drive	La Jolla	CA	Active
DSH050025AN	Child	DSH	UCSD MEDICAL CENTER	Cancer Center Radiation Oncology	3855 Health Sciences Dr.	La Jolla	CA	Active
DSH050025AP	Child	DSH	UCSD MEDICAL CENTER	Encinitas Radiation Oncology	1200 Garden View Road	Encinitas	CA	Active
DSH050025AQ	Child	DSH	UCSD MEDICAL CENTER	Sulpizio Cardiovascular Center / Emergency Room	9434 Medical Center Drive	La Jolla	CA	Active
DSH050025AR	Child	DSH	UCSD MEDICAL CENTER	Jacobs Medical Center / Operating Room	9300 Campus Point Drive	La Jolla	CA	Active
DSH050025AS	Child	DSH	UCSD MEDICAL CENTER	Jacobs Medical Center / PACU/SDP/Preeval	9300 Campus Point Drive	La Jolla	CA	Active
DSH050025AT	Child	DSH	UCSD MEDICAL CENTER	Sulpizio Cardiovascular Center / SCVC PTU	9434 Medical Center Drive	La Jolla	CA	Active
DSH050025AU	Child	DSH	UCSD MEDICAL CENTER	Jacobs Medical Center / Interventional Radiology	9300 Campus Point Drive	La Jolla	CA	Active
DSH050025AV	Child	DSH	UCSD MEDICAL CENTER	Jacobs Medical Center / Diagnostic Imaging	9300 Campus Point Drive	La Jolla	CA	Active
DSH050025AW	Child	DSH	UCSD MEDICAL CENTER	Jacobs Medical Center / CT Scan	9300 Campus Point Drive	La Jolla	CA	Active
DSH050025AX	Child	DSH	UCSD MEDICAL CENTER	Moores Cancer Center / Magnetic Resonance Imaging (MRI)	3855 Health Sciences Drive	La Jolla	CA	Active
DSH050025AY	Child	DSH	UCSD MEDICAL CENTER	Jacobs Medical Center / Magnetic Resonance Imaging (MRI)	9300 Campus Point Drive	La Jolla	CA	Active
DSH050025AZ	Child	DSH	UCSD MEDICAL CENTER	Sulpizio Cardiovascular Center / Cardiac Catheterization Labs	9434 Medical Center Drive	La Jolla	CA	Active
DSH050025BA	Child	DSH	UCSD MEDICAL CENTER	Sulpizio Cardiovascular Center / Electrophysiology Lab	9434 Medical Center Drive	La Jolla	CA	Active
DSH050025BB	Child	DSH	UCSD MEDICAL CENTER	Jacobs Medical Center / Physical Therapy	9300 Campus Point Drive	La Jolla	CA	Active
DSH050025BC	Child	DSH	UCSD MEDICAL CENTER	Sulpizio Cardiovascular Center / Non-Invasive Imaging	9434 Medical Center Drive	La Jolla	CA	Active
DSH050025BD	Child	DSH	UCSD MEDICAL CENTER	Jacobs Medical Center/ Pulmonary Lab	9300 Campus Point Drive	La Jolla	CA	Active
DSH050025BE	Child	DSH	UCSD MEDICAL CENTER	Jacobs Medical Center / Special Procedures Room	9300 Campus Point Drive	La Jolla	CA	Active
DSH050025BF	Child	DSH	UCSD MEDICAL CENTER	Jacobs Medical Center / Nuclear Medicine	9300 Campus Point Drive	La Jolla	CA	Active
DSH050025BG	Child	DSH	UCSD MEDICAL CENTER	Maternal-Fetal Care and Genetics	4910 Directors Place	San Diego	CA	Active
DSH050025BH	Child	DSH	UCSD MEDICAL CENTER	Senior Intensive Outpatient Psychiatry	410 Dickinson Street	San Diego	CA	Active
DSH050025BJ	Child	DSH	UCSD MEDICAL CENTER	Apheresis	3855 Health Sciences Drive	La Jolla	CA	Active
DSH050025BK	Child	DSH	UCSD MEDICAL CENTER	Jacobs Medical Center - Maternity and Delivery	9300 Campus Point Drive	La Jolla	CA	Active
DSH050025BL	Child	DSH	UCSD MEDICAL CENTER	Medical Offices South - Hillcrest Dermatology Clinic	4168 Front Street	San Diego	CA	Active
DSH050025BM	Child	DSH	UCSD MEDICAL CENTER	Jacobs Medical Center - EEG Program	9300 Campus Point Drive	La Jolla	CA	Active
DSH050025BN	Child	DSH	UCSD MEDICAL CENTER	Koman Family Outpatient Pavilion - Infusion Center	9400 Campus Point Drive	La Jolla	CA	Active
DSH050025BP	Child	DSH	UCSD MEDICAL CENTER	Koman Family Outpatient Pavilion - CT	9400 Campus Point Drive	La Jolla	CA	Active
DSH050025BQ	Child	DSH	UCSD MEDICAL CENTER	Koman Family Outpatient Pavilion - Ultrasound	9400 Campus Point Drive	La Jolla	CA	Active
DSH050025BR	Child	DSH	UCSD MEDICAL CENTER	Jacobs Medical Center - Cardiac Rehab	9300 Campus Point Drive	La Jolla	CA	Active
DSH050025BS	Child	DSH	UCSD MEDICAL CENTER	Koman Family Outpatient Pavilion - Special Procedure	9400 Campus Point Drive	La Jolla	CA	Active
DSH050025BT	Child	DSH	UCSD MEDICAL CENTER	Koman Family Outpatient Pavilion - Rehab Therapy	9400 Campus Point Drive	La Jolla	CA	Active
DSH050025BU	Child	DSH	UCSD MEDICAL CENTER	Koman Family Outpatient Pavilion - Diagnostic	9400 Campus Point Drive	La Jolla	CA	Active
DSH050025BV	Child	DSH	UCSD MEDICAL CENTER	Koman Family Outpatient Pavilion - MRI	9400 Campus Point Drive	La Jolla	CA	Active
DSH050025BW	Child	DSH	UCSD MEDICAL CENTER	Koman Family Outpatient Pavilion - Apheresis	9400 Campus Point Drive	La Jolla	CA	Active
DSH050025BX	Child	DSH	UCSD MEDICAL CENTER	Koman Family Outpatient Pavilion - Orthopedics and Sports Medicine	9400 Campus Point Drive	La Jolla	CA	Active
DSH050025BY	Child	DSH	UCSD MEDICAL CENTER	Koman Family Outpatient Pavilion - Urology	9400 Campus Point Drive	La Jolla	CA	Active
DSH050025BZ	Child	DSH	UCSD MEDICAL CENTER	Koman Family Outpatient Pavilion - Pre-Op/PACU	9400 Campus Point Drive	La Jolla	CA	Active
DSH050025CA	Child	DSH	UCSD MEDICAL CENTER	Koman Family Outpatient Pavilion - Breast Imaging	9400 Campus Point Drive	La Jolla	CA	Active
DSH050025CB	Child	DSH	UCSD MEDICAL CENTER	Koman Family Outpatient Pavilion - Operating Room	9400 Campus Point Drive	La Jolla	CA	Active
DSH050025CC	Child	DSH	UCSD MEDICAL CENTER	Koman Family Outpatient Pavilion - Pain Clinic	9400 Campus Point Drive	La Jolla	CA	Active
DSH050025CD	Child	DSH	UCSD MEDICAL CENTER	Koman Family Outpatient Pavilion - Breast Clinic	9400 Campus Point Drive	La Jolla	CA	Active
DSH050025CE	Child	DSH	UCSD MEDICAL CENTER	Koman Family Outpatient Pavilion - Sanford Center	9400 Campus Point Drive	La Jolla	CA	Active
DSH050025CF	Child	DSH	UCSD MEDICAL CENTER	Medical Offices South - Hillcrest Hospitalist OB Clinic	4168 Front Street	San Diego	CA	Active
DSH050025CG	Child	DSH	UCSD MEDICAL CENTER	Directors Place - Sorrento Valley - Sorrento Womens Health Services	4910 Directors Place	San Diego	CA	Active
DSH050025CH	Child	DSH	UCSD MEDICAL CENTER	Jacobs Medical Center - Dialysis	9300 Campus Point Drive	La Jolla	CA	Active
DSH050025CJ	Child	DSH	UCSD MEDICAL CENTER	Koman Family Outpatient Pavilion - Vascular Surgery	9400 Campus Point Drive	La Jolla	CA	Active
DSH050025CK	Child	DSH	UCSD MEDICAL CENTER	Jacobs Medical Center - Motility Clinic	9300 Campus Point Drive	La Jolla	CA	Active
DSH050025CL	Child	DSH	UCSD MEDICAL CENTER	Radiation Oncology - Mobile PET/CT	9436 Medical Center Drive	La Jolla	CA	Active
DSH050025CM	Child	DSH	UCSD MEDICAL CENTER	Medical Offices South - Pulmonary Rehab	4168 Front Street	San Diego	CA	Active
DSH050025CN	Child	DSH	UCSD MEDICAL CENTER	Jacobs Medical Center - La Jolla Ultrasound	9300 Campus Pt Drive	La Jolla	CA	Active
DSH050025CP	Child	DSH	UCSD MEDICAL CENTER	Jacobs Medical Center - Rapid Recovery	9300 Campus Pt Drive	La Jolla	CA	Active
DSH050025CQ	Child	DSH	UCSD MEDICAL CENTER	Koman Family Outpatient Pavilion - KOP Cancer Clinic	9400 Campus Point Drive	La Jolla	CA	Active
DSH050025CR	Child	DSH	UCSD MEDICAL CENTER	Medical Offices South - Pain Management Clinic	4168 Front Street	San Diego	CA	Active
DSH050025CS	Child	DSH	UCSD MEDICAL CENTER	East Campus Medical Center - Pre-Op / Post-Op	6655 Alvarado Road	San Diego	CA	Active
DSH050025CT	Child	DSH	UCSD MEDICAL CENTER	Radiation Oncology PET/CT Center - Radiation Oncology	3960 Health Sciences Drive	La Jolla	CA	Active
DSH050025CU	Child	DSH	UCSD MEDICAL CENTER	East Campus Medical Center - Emergency	6655 Alvarado Road	San Diego	CA	Active
DSH050025CV	Child	DSH	UCSD MEDICAL CENTER	East Campus Medical Center - Dialysis	6655 Alvarado Road	San Diego	CA	Active
DSH050025CW	Child	DSH	UCSD MEDICAL CENTER	East Campus Medical Center - Physical Therapy	6645 Alvarado Road	San Diego	CA	Active
DSH050025CX	Child	DSH	UCSD MEDICAL CENTER	East Campus Medical Center - Special Procedures	6655 Alvarado Road	San Diego	CA	Active
DSH050025CY	Child	DSH	UCSD MEDICAL CENTER	East Campus Medical Center - EP Lab	6655 Alvarado Road	San Diego	CA	Active
DSH050025CZ	Child	DSH	UCSD MEDICAL CENTER	East Campus Medical Center - Diagnostic Imaging	6655 Alvarado Road	San Diego	CA	Active
DSH050025D	Child	DSH	UCSD MEDICAL CENTER	East Campus Medical Center - Interventional Radiology	6655 Alvarado Road	San Diego	CA	Active
DSH050025DA	Child	DSH	UCSD MEDICAL CENTER	East Campus Medical Center - Surgery	6655 Alvarado Road	San Diego	CA	Active
DSH050025DB	Child	DSH	UCSD MEDICAL CENTER	East Campus Medical Center - CT	6655 Alvarado Road	San Diego	CA	Active
DSH050025DC	Child	DSH	UCSD MEDICAL CENTER	East Campus Medical Center - Ultrasound	6655 Alvarado Road	San Diego	CA	Active
DSH050025DD	Child	DSH	UCSD MEDICAL CENTER	East Campus Medical Center - Nuclear Medicine	6655 Alvarado Road	San Diego	CA	Active
DSH050025DE	Child	DSH	UCSD MEDICAL CENTER	East Campus Medical Center - MRI	6655 Alvarado Road	San Diego	CA	Active
DSH050025DF	Child	DSH	UCSD MEDICAL CENTER	East Campus Medical Center - Cath Lab	6655 Alvarado Road	San Diego	CA	Active
DSH050025DG	Child	DSH	UCSD MEDICAL CENTER	East Campus Medical Center - Non-Invasive Imaging	6655 Alvarado Road	San Diego	CA	Active
DSH050025DH	Child	DSH	UCSD MEDICAL CENTER	UCSD Medical Center Hillcrest - Ambulatory Infusion	200 West Arbor Drive	San Diego	CA	Approved
DSH050025DJ	Child	DSH	UCSD MEDICAL CENTER	UCSD Medical Offices North - GI Clinic	200 West Arbor Drive	San Diego	CA	Approved
DSH050025DK	Child	DSH	UCSD MEDICAL CENTER	UCSD Medical Offices North - Cancer Center Clinic	200 West Arbor Drive	San Diego	CA	Approved
DSH050025DL	Child	DSH	UCSD MEDICAL CENTER	UCSD Medical Offices North - Vascular	200 West Arbor Drive	San Diego	CA	Approved
DSH050025DM	Child	DSH	UCSD MEDICAL CENTER	UCSD Medical Offices North - Gastroenterology Suite	200 West Arbor Drive	San Diego	CA	Approved
DSH050025K	Child	DSH	UCSD MEDICAL CENTER	Shiley Eye Center	9415 Campus Pt. Drive	La Jolla	CA	Active
DSH050025L	Child	DSH	UCSD MEDICAL CENTER	Encinitas Hyperbaric Medicine Center	477 N. El Camino Real Ste D-204	Encinitas	CA	Active
DSH050025M	Child	DSH	UCSD MEDICAL CENTER	UCSD Medical Offices South - Multi-Specialty Clinic	4168 Front Street	San Diego	CA	Terminated
DSH050025N	Child	DSH	UCSD MEDICAL CENTER	UCSD Medical Offices South - Chronic Kidney Disease Clinic	4168 Front Street	San Diego	CA	Active
DSH050025P	Child	DSH	UCSD MEDICAL CENTER	UCSD Medical Offices South - Adult Specialties	4168 Front Street	San Diego	CA	Active
DSH050025Q	Child	DSH	UCSD MEDICAL CENTER	UCSD Medical Offices South - Medicine Specialties	4168 Front Street	San Diego	CA	Active
DSH050025R	Child	DSH	UCSD MEDICAL CENTER	UCSD Medical Offices South - Cardiology Clinic	4168 Front Street	San Diego	CA	Active
DSH050025S	Child	DSH	UCSD MEDICAL CENTER	UCSD Medical Offices South - Owen Clinic	4168 Front Street	San Diego	CA	Active
DSH050025T	Child	DSH	UCSD MEDICAL CENTER	UCSD Medical Offices South - Primary Care OB/GYN	4168 Front Street	San Diego	CA	Active
DSH050025U	Child	DSH	UCSD MEDICAL CENTER	UCSD Medical Offices South - Community Women's Health Plan	4168 Front Street	San Diego	CA	Active
DSH050025V	Child	DSH	UCSD MEDICAL CENTER	UCSD Medical Offices North - Neurology Clinic	200 West Arbor Drive	San Diego	CA	Active
DSH050025W	Child	DSH	UCSD MEDICAL CENTER	UCSD Medical Offices North - Head and Neck Surgery	200 West Arbor Drive	San Diego	CA	Active
DSH050025X	Child	DSH	UCSD MEDICAL CENTER	UCSD Medical Offices North - Surgery Clinic	200 West Arbor Drive	San Diego	CA	Active
DSH050025Y	Child	DSH	UCSD MEDICAL CENTER	UCSD Medical Offices North - GU Clinic	200 West Arbor Drive	San Diego	CA	Active
DSH050025Z	Child	DSH	UCSD MEDICAL CENTER	UCSD Medical Offices North - Orthopedics	200 West Arbor Drive	San Diego	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Donaldson, Lori CFO UCSD Medical Center 6195436613	4/17/2025 10:20 AM
Details	340B ID	Update	New Registration		DSH050025DM	4/17/2025 10:20 AM
Details	Entity Subname	Update	New Registration	UCSD Medical Offices North	UCSD Medical Offices North - Gastroenterology Suite	4/17/2025 10:20 AM
Dates	Participating Approval Date	Update	New Registration		4/17/2025 10:20:31 AM	4/17/2025 10:20 AM
Details	State	Update	New Registration	Pending	Approved	4/17/2025 10:20 AM
Dates	Signed By Date	Update	New Registration		4/15/2025 12:18:51 PM	4/17/2025 10:20 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/17/2025 10:20 AM
Addresses	Main Address	Insert	New Registration		200 West Arbor Drive San Diego, CA 92103	4/11/2025 6:17 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1184722779	4/11/2025 6:17 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/11/2025 6:17 PM
Contacts	Authorizing Official	Insert	New Registration		Donaldson, Lori CFO UCSD Medical Center 6195436613	4/11/2025 6:17 PM
Contacts	Primary Contact	Insert	New Registration		Tolentino, Katrina 340B Program Coordinator UCSD Medical Center 6195433104	4/11/2025 6:17 PM
Details	Assistance Received From Date	Insert	New Registration			4/11/2025 6:17 PM
Details	Assistance Received To Date	Insert	New Registration			4/11/2025 6:17 PM
Details	Last Recertification Date	Insert	New Registration			4/11/2025 6:17 PM
Details	Grant Number	Insert	New Registration			4/11/2025 6:17 PM
Details	340B ID	Insert	New Registration			4/11/2025 6:17 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/11/2025 6:17 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/11/2025 6:17 PM
Details	Medicare Provider Number	Insert	New Registration		050025	4/11/2025 6:17 PM
Details	Entity Name	Insert	New Registration		UCSD MEDICAL CENTER	4/11/2025 6:17 PM
Details	NOFO Number	Insert	New Registration			4/11/2025 6:17 PM
Details	Program Code	Insert	New Registration		DSH	4/11/2025 6:17 PM
Details	Entity Subname	Insert	New Registration		UCSD Medical Offices North	4/11/2025 6:17 PM
Dates	Participating Approval Date	Insert	New Registration			4/11/2025 6:17 PM
Details	State	Insert	New Registration		Pending	4/11/2025 6:17 PM
Dates	Registration Date	Insert	New Registration		4/11/2025 6:17:03 PM	4/11/2025 6:17 PM
Dates	Signed By Date	Insert	New Registration			4/11/2025 6:17 PM
Dates	Start Date	Insert	New Registration			4/11/2025 6:17 PM
Terminations	Termination Comments	Insert	New Registration			4/11/2025 6:17 PM
Terminations	Termination Date	Insert	New Registration			4/11/2025 6:17 PM
Terminations	Termination Effective Date	Insert	New Registration			4/11/2025 6:17 PM
Terminations	Termination Reason	Insert	New Registration			4/11/2025 6:17 PM