Covered Entity Details

DSH050025 UCSD MEDICAL CENTER (Active) - information as of 5/16/2025 11:22:11 PM

Main Details

Name

UCSD MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH050025

Medicare Provider Number

050025

Additional Details

Current Program Status

Active

Registration Date

10/30/2007

Participating Start Date

12/1/1992

Participating Approval Date

10/30/2007

Last Recertification Date

8/27/2024

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
4/10/2014 - Multiple terminations/reinstatements recorded in error; site remained continuously eligible from participation start date. 10/21/09 ADDED MEDICAID#	04/14/2014
10/21/09 ADDED MEDICAID# 03/25/2014: Termination recorded in error; site remained continuously eligible from participation start date.	03/31/2014
10/21/09 ADDED MEDICAID#	10/30/2007

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
AK	1005640	1184722779
ME	1184722779	1184722779
VT	0050025	1184722779
MT	1184722779	1184722779
SD	1184722779	1184722779
NC	1184722779	1184722779
AL	UCS0025N	1184722779
TN	1509192	1184722779
MO	016210007	1184722779
MD	41578000	1184722779
NE	10026299201	1184722779
MS	000788675	1184722779
KY	01200377	1184722779
NH	3137541	1184722779
AZ	309479	1184722779
CT	003127322	1184722779
ID	1184722779	1184722779
KS	30003889620001	1184722779
TX	112752403	1184722779
LA	3818434	1184722779
NM	000B1495	1184722779
FL	115505500	1184722779
HI	536005	1184722779
WA	2261049	1184722779
IN	30085399	1184722779
VA	1184722779	1184722779
MA	110027530D	1184722779
RI	1184722779	1184722779
CO	02328542	1184722779
DE	250467504	1184722779
GA	000157495X	1184722779
IL	330599494001	1184722779
IA	0548636	1184722779
MI	1184722779	1184722779
MN	1184722779	1184722779
NV	1184722779	1184722779
NY	02913739	1184722779
OH	7673405	1184722779
OK	100690800A	1184722779
OR	297530	1184722779
SC	11781B	1184722779
UT	1184722779	1184722779
WI	81008100	1184722779
CA		1598786576,1316968399,1952322935,1730273582,1013359462,1184722779,1518300532,1417670688

Shipping Addresses

Shipping Address 1

UCSD SDCC Infusion Pharmacy
1200 Garden View Rd Ste 200
Encinitas, CA 92024

Shipping Address 2

UCSD Health La Jolla Jacobs Med Center & Sulpizio Cardiovascular Center
9300 Campus Point Drive
La Jolla, CA 92037

Shipping Address 3

UCSD Medical Offices South Pharmacy
4168 Front Street
San Diego, CA 92103

Shipping Address 4

The John M & Sally B Thornton Hospital
9300 Campus Point Dr Rm LL-463
La Jolla, CA 92037

Shipping Address 5

UCSD Medical Center Pharmacy
200 West Arbor Drive
Room I317
San Diego, CA 92103-8765

Shipping Address 6

UCSD Home Infusion Pharmacy
9610 Ridgehaven Court
Suite A
San Diego, CA 92123

Shipping Address 7

UCSD Moores Cancer Center
3855 Health Science Drive
RM 1036
La Jolla, CA 92093

Shipping Address 8

SAFECOR/ UCSD MEDICAL CENTER
4060 BUSINESS PARK DRIVE
SUITE B
COLUMBUS, OH 43204

Shipping Address 9

UCSD-SDCC Retail Pharmacy
1200 Garden View Road
Suite 103
Encinitas, CA 92024

Shipping Address 10

UCSD Outpatient Pavilion Pharmacy
9400 Campus Point Drive
Room 3-400A
La Jolla, CA 92037

Shipping Address 11

UCSD Specialty Pharmacy
9610 Ridgehaven Ct Ste C
San Diego, CA 92123-5603

Shipping Address 12

UCSD East Campus Medical Center Pharmacy
6655 Alvarado Rd
San Diego, CA 92120

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACARIAHEALTH PHARMACY #13, INC	3302 GARFIELD AVE.		COMMERCE	CA	90040-3102	04/13/2017	07/01/2017	02/15/2025	02/15/2025
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/22/2015	07/01/2015		07/12/2017
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/22/2015	07/01/2015		07/12/2017
Contract Detail	ACCREDO HEALTH GROUP INC	201 GREAT CIRCLE ROAD		NASHVILLE	TN	37228	04/22/2015	07/01/2015	06/17/2016	07/12/2017
Contract Detail	ACCREDO HEALTH GROUP INC	2410 WARDLOW RD	STE 101	CORONA	CA	92878	04/22/2015	07/01/2015		07/12/2017
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/10/2017	07/01/2017		07/12/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	04/22/2015	07/01/2015	01/05/2018	01/05/2018
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/22/2015	07/01/2015	07/16/2017	07/14/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.		PHARMACY 2 BOULDEN CIRCLE SUITE 1	NEW CASTLE	DE	19720	04/22/2015	07/01/2015	07/02/2015	07/12/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	07/09/2015	10/01/2015	07/16/2017	07/14/2017
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	07/05/2017	10/01/2017	03/28/2018	04/03/2018
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	04/14/2020	07/01/2020	08/31/2021	10/04/2021
Contract Detail	AHF PHARMACY	AIDS HEALTHCARE FOUNDATION	1988 HACIENDA DR	VISTA	CA	92081-6026	12/13/2020	12/14/2020		12/14/2020
Contract Detail	AHF PHARMACY	AIDS HEALTHCARE FOUNDATION	120 UNIVERSITY AVE	SAN DIEGO	CA	92103-3007	12/13/2020	12/14/2020		12/14/2020
Contract Detail	AIDS HEALTHCARE FOUNDATION	DBA AHF PHARMACY	19300 S. HAMILTON AVE #170/180	GARDENA	CA	90248-4400	07/17/2013	10/01/2013		07/12/2017
Contract Detail	AIDS HEALTHCARE FOUNDATION	AHF PHARMACY	3580 5TH AVE STE 200	SAN DIEGO	CA	92103	07/17/2013	10/01/2013		07/12/2017
Contract Detail	AIDS HEALTHCARE FOUNDATION	DBA AHF PHARMACY	5417 E. WHITTIER BLVD	LOS ANGELES	CA	90022-4101	07/17/2013	10/01/2013	01/07/2016	07/12/2017
Contract Detail	BIOLOGICS, INC.	BIOLOGICS BY MCKESSON	11800 WESTON PARKWAY	CARY	NC	27513	01/17/2023	04/01/2023		04/01/2023
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	13925 YALE AVE STE 145		IRVINE	CA	92620-2670	04/27/2023	07/01/2023		07/01/2023
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	04/27/2023	07/01/2023		07/01/2023
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	04/27/2023	07/01/2023		07/01/2023
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4740 VICTORY LN STE C	INDIANAPOLIS	IN	46203	07/24/2024	10/01/2024		10/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	145 S 79TH ST STE 70	CHANDLER	AZ	85226	07/24/2024	10/01/2024		10/01/2024
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	04/08/2016	07/01/2016	06/30/2017	07/14/2017
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/15/2022	10/01/2022		10/01/2022
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/08/2016	07/01/2016		07/12/2017
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/08/2016	07/01/2016		07/12/2017
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	04/08/2016	07/01/2016	06/30/2017	07/14/2017
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/15/2022	10/01/2022		10/01/2022
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	04/08/2016	07/01/2016	06/30/2017	07/14/2017
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/15/2022	10/01/2022		10/01/2022
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/08/2016	07/01/2016	06/30/2017	07/14/2017
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/14/2020	07/01/2020		07/01/2020
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	04/08/2016	07/01/2016	06/30/2017	07/14/2017
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/15/2022	10/01/2022		10/01/2022
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/08/2016	07/01/2016	06/30/2017	07/14/2017
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/14/2020	07/01/2020		07/01/2020
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/08/2016	07/01/2016		07/12/2017
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/15/2022	10/01/2022		10/01/2022
Contract Detail	CENTERWELL PHARMACY, INC.	9843 WINDISCH RD		WEST CHESTER	OH	45069	10/12/2020	01/01/2021		01/01/2021
Contract Detail	CENTERWELL PHARMACY, INC.	11010 FLORIDA CROWN DRIVE, SUITE 200		ORLANDO	FL	32824	07/24/2024	10/01/2024		10/01/2024
Contract Detail	COMMUNITY MEDICAL CENTER PHARMACY		750 MEDICAL CENTER CRT STE. 1	CHULA VISTA	CA	91911-6634	07/17/2013	10/01/2013	01/27/2017	07/12/2017
Contract Detail	COMMUNITY MEDICAL PHARMACY	IN-HOUSE PHARMACIES, INC.	610 GATEWAY CENTER WAY NO. A	SAN DIEGO	CA	92102-4548	08/20/2012	08/20/2012	03/09/2018	03/16/2018
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	12310 WORLD TRADE DRIVE SUITE 100	SAN DIEGO	CA	92128	04/13/2017	07/01/2017		07/12/2017
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	3101 SILLECT AVENUE, SUITE 109	BAKERSFIELD	CA	93308-6348	04/13/2017	07/01/2017	08/09/2017	08/14/2017
Contract Detail	CORAM HEALTHCARE CORP OF SOUTHERN CALIFO	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	2710 MEDIA CENTER DRIVE, BLDG. #6, SUITE 150	LOS ANGELES	CA	90065	04/13/2017	07/01/2017	02/26/2019	03/05/2019
Contract Detail	CORAM HEALTHCARE CORP OF SOUTHERN CALIFO	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	4355 EAST LOWELL STREET SUITE C	ONTARIO	CA	91761	04/13/2017	07/01/2017	02/26/2019	03/05/2019
Contract Detail	CORAM HEALTHCARE CORPORATION OF NEVADA	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	1951 RAMROD AVENUE SUITE 110	HENDERSON	NV	89014-2314	04/13/2017	07/01/2017	08/09/2017	08/14/2017
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	07/14/2021	10/01/2021		10/01/2021
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	07/14/2021	10/01/2021		10/01/2021
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/15/2022	10/01/2022		10/01/2022
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	07/13/2020	10/01/2020		10/01/2020
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	07/07/2016	10/01/2016	01/18/2022	01/24/2022
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	1370 BUSCH PKWY		BUFFALO GROVE	IL	60089-4505	07/06/2016	10/01/2016	09/09/2016	07/12/2017
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	G3320 BEECHER RD		FLINT	MI	48532-3614	07/06/2016	10/01/2016	06/22/2017	07/12/2017
Contract Detail	DIPLOMAT SPECIALTY PHARMACY OF FT LAUDER	DIPLOMAT SPECIALTY PHARMACY	15471 SW 12TH ST STE 207	SUNRISE	FL	33326	07/06/2016	10/01/2016	09/09/2016	07/12/2017
Contract Detail	DIPLOMAT SPECIALTY PHARMACY OF PHOENIX,	DIPLOMAT SPECIALTY PHARMACY	485 N. JUNIPER DR	CHANDLER	AZ	85226	07/11/2019	10/01/2019	06/16/2020	06/19/2020
Contract Detail	DIPLOMAT SPECIALTY PHARMACY OF SOUTHERN	DIPLOMAT SPECIALTY PHARMACY	1809 EXCISE AVENUE SUITE 204-208	ONTARIO	CA	91761	07/06/2016	10/01/2016	08/01/2019	10/08/2019
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	10/05/2018	01/01/2019		01/01/2019
Contract Detail	GALLOWAY'S MEDICAL CENTER PHARMACY	2995 NATIONAL AVENUE		SAN DIEGO	CA	92113	08/20/2012	08/20/2012	03/09/2018	03/16/2018
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09138	1201 E. PLAZA BLVD	NATIONAL CITY	CA	91950	01/14/2015	04/01/2015	04/26/2017	07/12/2017
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09141	3151 UNIVERSITY AVE.	SAN DIEGO	CA	92104	01/14/2015	04/01/2015	04/26/2017	07/12/2017
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09148	313 WASHINGTON ST.	SAN DIEGO	CA	92103	01/14/2015	04/01/2015		07/12/2017
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09195	8831 VILLA LA JOLLA DR.	LA JOLLA	CA	92037	01/14/2015	04/01/2015		07/12/2017
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 04768	510 C STREET	SAN DIEGO	CA	92101	10/12/2018	01/01/2019		01/01/2019
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09175	4829 CLAIREMONT DR	SAN DIEGO	CA	92117	10/12/2018	01/01/2019		01/01/2019
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09141	3151 UNIVERSITY AVE.	SAN DIEGO	CA	92104	10/12/2018	01/01/2019		01/01/2019
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09177	8260 MIRA MESA BLVD.	SAN DIEGO	CA	92126	10/12/2018	01/01/2019		01/01/2019
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09112	7100 BROADWAY	LEMON GROVE	CA	91945	10/12/2018	01/01/2019		01/01/2019
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09138	1201 E. PLAZA BLVD	NATIONAL CITY	CA	91950	10/12/2018	01/01/2019		01/01/2019
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09479	2510 EL CAMINO REAL	CARLSBAD	CA	92008	10/12/2018	01/01/2019		01/01/2019
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09193	1380 43RD ST.	SAN DIEGO	CA	92113	10/12/2018	01/01/2019		01/01/2019
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09103	318 W EL NORTE PARKWAY	ESCONDIDO	CA	92026	04/08/2019	07/01/2019	12/01/2024	12/16/2024
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09524	3350 PALM AVE.	SAN DIEGO	CA	92154	04/08/2019	07/01/2019	12/01/2024	12/16/2024
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09109	6265 EL CAJON BLVD	SAN DIEGO	CA	92115	04/08/2019	07/01/2019		07/01/2019
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09121	4404 EL CAJON BLVD	SAN DIEGO	CA	92115	04/08/2019	07/01/2019		07/01/2019
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09113	645 E. PALOMAR ST.	CHULA VISTA	CA	91911	01/14/2020	04/01/2020		04/01/2020
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08859	16 3RD AVENUE EXT.	CHULA VISTA	CA	91910	01/14/2020	04/01/2020		04/01/2020
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09145	9730 MISSION GORGE RD.	SANTEE	CA	92071	04/14/2020	07/01/2020		07/01/2020
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09528	7740 RANCHO SANTA FE ROAD	CARLSBAD	CA	92009	04/14/2020	07/01/2020	12/01/2024	12/16/2024
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09194	1810 MAIN ST.	RAMONA	CA	92065	04/14/2020	07/01/2020		07/01/2020
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09187	683 LOMAS SANTA FE DR.	SOLANA BEACH	CA	92075	04/14/2020	07/01/2020	12/01/2024	12/16/2024
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09104	2427 E. VALLEY PKWY	ESCONDIDO	CA	92027	04/14/2020	07/01/2020	03/31/2023	04/27/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16937	2295 N IMPERIAL AVE	EL CENTRO	CA	92243	04/14/2020	07/01/2020	03/31/2023	04/27/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09137	7393 JACKSON DR.	SAN DIEGO	CA	92119	04/14/2020	07/01/2020		07/01/2020
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09181	455 ENCINITAS BLVD.	ENCINITAS	CA	92024	04/14/2020	07/01/2020	03/31/2023	04/27/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09115	645 SATURN BLVD	SAN DIEGO	CA	92154	04/14/2020	07/01/2020		07/01/2020
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09165	3327 ROSECRANS ST.	SAN DIEGO	CA	92110	07/14/2021	10/01/2021	12/01/2024	12/16/2024
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY #10819	1850 5TH AVENUE	SAN DIEGO	CA	92101	07/14/2021	10/01/2021	03/31/2023	04/27/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09140	555 BROADWAY STE 1054	CHULA VISTA	CA	91910	07/14/2021	10/01/2021	03/31/2023	04/27/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS/PHARMACY # 17745	3029 UNIVERSITY AVE.	SAN DIEGO	CA	92104	01/17/2023	04/01/2023		04/01/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09197	9225 TWIN TRAILS DRIVE	SAN DIEGO	CA	92129	01/17/2023	04/01/2023		04/01/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08833	3332 SANDROCK ROAD	SAN DIEGO	CA	92123	01/17/2023	04/01/2023		04/01/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09120	800 PALM AVE.	IMPERIAL BEACH	CA	91932	01/17/2023	04/01/2023		04/01/2023
Contract Detail	GENOA HEALTHCARE LLC	1701 MISSION AVE STE 230 RM P1		OCEANSIDE	CA	92058	04/26/2021	07/01/2021	06/01/2022	06/01/2022
Contract Detail	GENOA HEALTHCARE LLC	1850 W FLORIDA AVE		HEMET	CA	92545	04/28/2021	07/01/2021	06/01/2022	06/01/2022
Contract Detail	GENOA HEALTHCARE LLC	245 11TH ST STE P1		SAN FRANCISCO	CA	94103	04/28/2021	07/01/2021	06/01/2022	06/01/2022
Contract Detail	GENOA HEALTHCARE LLC	17782 COWAN ST STE G		IRVINE	CA	92614	04/28/2021	07/01/2021	06/01/2022	06/01/2022
Contract Detail	GENOA HEALTHCARE LLC	11721 E TELEGRAPH RD UNIT I		SANTA FE SPRINGS	CA	90670	04/28/2021	07/01/2021	06/01/2022	06/01/2022
Contract Detail	HILLCREST PHARMACY	120 UNIVERSITY AVE		SAN DIEGO	CA	92103	08/20/2012	08/20/2012	12/14/2020	12/14/2020
Contract Detail	HILLCREST PHARMACY INC	HILLCREST PHARMACY	1988 HACIENDA DR	VISTA	CA	92081-6026	01/20/2016	04/01/2016	12/14/2020	03/30/2024
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09538	1792 GARNET AVE	SAN DIEGO	CA	92109	01/14/2015	04/01/2015	04/26/2017	07/12/2017
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09926	7525 EADS AVE	LA JOLLA	CA	92037	01/14/2015	04/01/2015	12/01/2024	12/16/2024
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09538	1792 GARNET AVE	SAN DIEGO	CA	92109	10/12/2018	01/01/2019		01/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 07962	5685 BALBOA AVE	SAN DIEGO	CA	92111	04/08/2019	07/01/2019		07/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09963	5644 MISSION CENTER RD SUITE 201	SAN DIEGO	CA	92108	04/08/2019	07/01/2019	04/08/2019	04/09/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09963	5644 MISSION CENTER RD SUITE 201	SAN DIEGO	CA	92108	04/08/2019	07/01/2019		07/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09162	3749 AVOCADO BLVD	LA MESA	CA	91941	04/08/2019	07/01/2019		07/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 06332	645 MARKET ST	SAN DIEGO	CA	92101	01/14/2020	04/01/2020		04/01/2020
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09937	4445 MISSION BLVD	SAN DIEGO	CA	92109	04/14/2020	07/01/2020		07/01/2020
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09135	129 N EL CAMINO REAL	ENCINITAS	CA	92024	04/14/2020	07/01/2020	12/01/2024	12/16/2024
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09247	2662 DEL MAR HEIGHTS RD	DEL MAR	CA	92014	07/14/2021	10/01/2021		10/01/2021
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09169	5500 GROSSMONT CENTER DR BLDG P	LA MESA	CA	91942	01/17/2023	04/01/2023		04/01/2023
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09154	10350 FRIARS RD	SAN DIEGO	CA	92120	01/17/2023	04/01/2023		04/01/2023
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09632	691 3RD AVE	CHULA VISTA	CA	91910	01/17/2023	04/01/2023	12/01/2024	12/16/2024
Contract Detail	MEDICAL CENTER PHARMACY	340 4TH AVENUE	SUITE 1	CHULA VISTA	CA	91910	08/20/2012	08/20/2012	03/09/2018	03/16/2018
Contract Detail	MEDICAL CENTER PHARMACY	3904 PARK BLVD		SAN DIEGO	CA	92103	08/20/2012	08/20/2012	03/09/2018	03/16/2018
Contract Detail	MEDICAL CENTER PHARMACY	4074 FAIRMONT AVENUE		SAN DIEGO	CA	92105	08/20/2012	08/20/2012	03/09/2018	03/16/2018
Contract Detail	MEDICAL CENTER PHARMACY	PARK MEDICAL PHARMACY	480 4TH AVE STE 100	CHULA VISTA	CA	91910	07/17/2013	10/01/2013	03/09/2018	03/16/2018
Contract Detail	MEDICAL CENTER PHARMACY	MEDICAL CENTER PHARMACY	855 THIRD AVENUE SUITE 1102	CHULA VISTA	CA	91911-9210	07/17/2013	10/01/2013	01/27/2017	07/12/2017
Contract Detail	MEDICAL CENTER PHARMACY		7910 FROST STREET SUITE 130	SAN DIEGO	CA	92123	07/17/2013	10/01/2013	06/17/2016	07/12/2017
Contract Detail	MEDICAL CENTER PHARMACY	MCP16	286 EUCLID AVE, #206	SAN DIEGO	CA	92114	01/14/2015	04/01/2015	08/12/2017	08/14/2017
Contract Detail	MI FARMACIA SAN YSIDRO	4630 BORDER VILLAGE RD STE K-L		SAN YSIDRO	CA	92173-3121	04/26/2019	07/01/2019	06/16/2020	06/19/2020
Contract Detail	MISSION PLAZA PHARMACY	26800 CROWN VALLEY PKWY STE 185		MISSION VIEJO	CA	92691-7304	07/24/2014	10/01/2014	05/10/2022	05/19/2022
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	07/06/2017	10/01/2017	01/01/2021	01/08/2021
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	10/13/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM FRONTIER THERAPIES, LLC	325 W ATHERTON RD	SUITE 1	FLINT	MI	48507-2601	10/13/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	01/08/2021	04/01/2021		04/01/2021
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	01/14/2022	01/18/2022		01/18/2022
Contract Detail	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	10/13/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	07/06/2017	10/01/2017		07/12/2017
Contract Detail	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	10/25/2021	01/01/2022		01/01/2022
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	07/06/2017	10/01/2017	04/15/2019	04/26/2019
Contract Detail	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	10/25/2021	01/01/2022		01/01/2022
Contract Detail	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	10/12/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	07/15/2019	10/01/2019	07/01/2019	09/09/2019
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	01/08/2021	04/01/2021		04/01/2021
Contract Detail	OPTUM PHARMACY 806, INC.	2288 AUBURN BLVD	STE. 102	SACRAMENTO	CA	95821-1618	07/15/2019	10/01/2019	08/31/2021	10/04/2021
Contract Detail	OPTUMRX	2858 LOKER AVE E STE 100		CARLSBAD	CA	92010-6608	01/14/2020	04/01/2020	06/01/2022	06/01/2022
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	10/25/2021	01/01/2022		01/01/2022
Contract Detail	PHARMEDQUEST PHARMACY SERVICES	DBA AVITA PHARMACY 1072	26800 CROWN VALLEY PKWY STE 185	MISSION VIEJO	CA	92691	05/09/2022	05/10/2022		05/10/2022
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	07/13/2020	10/01/2020	07/01/2022	07/15/2022
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/08/2016	07/01/2016		07/12/2017
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY	1010 UNIVERSITY AVENUE	SAN DIEGO	CA	92103	07/14/2017	10/01/2017	03/28/2018	04/03/2018
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY	1010 UNIVERSITY AVENUE	SAN DIEGO	CA	92103	10/12/2018	01/01/2019		01/01/2019
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY	8607 SANTA MONICA BOULEVARD	WEST HOLLYWOOD	CA	90069	04/14/2020	07/01/2020		07/01/2020
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/15/2022	10/01/2022		10/01/2022
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/15/2022	10/01/2022		10/01/2022
Contract Detail	RALPHS GROCERY CO	DBA RALPHS #108	8657 VILLA LA JOLLA DR #108	LA JOLLA	CA	92037	12/05/2012	12/05/2012	07/01/2023	07/19/2023
Contract Detail	RALPHS GROCERY CO	DBA RALPHS #207	4315 MISSION BLVD	SAN DIEGO	CA	92109	12/05/2012	12/05/2012	04/15/2019	04/26/2019
Contract Detail	RALPHS GROCERY CO	DBA RALPHS #51	1020 UNIVERSITY AVE	SAN DIEGO	CA	92103	12/05/2012	01/01/2013	07/01/2023	07/19/2023
Contract Detail	RALPHS GROCERY CO	DBA RALPHS #123	101 G ST.	SAN DIEGO	CA	92101	10/14/2014	01/01/2015	02/15/2025	02/15/2025
Contract Detail	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	04/27/2023	07/01/2023		07/01/2023
Contract Detail	SANTA BARBARA SPECIALTY PHARMACY LLC	4690 CARPINTERIA AVE STE B		CARPINTERIA	CA	93013	07/24/2024	10/01/2024		10/01/2024
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #2053	3645 MIDWAY DRIVE	SAN DIEGO	CA	92110	12/31/2012	12/31/2012	05/15/2019	05/28/2019
Contract Detail	THE VONS COMPANIES INC	PAVILIONS PHARMACY #2323	7544 GIRARD AVENUE	LA JOLLA	CA	92037	12/31/2012	12/31/2012	11/01/2020	11/16/2020
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #1797	4627 CARMEL MOUNTAIN ROAD	SAN DIEGO	CA	92130	12/31/2012	12/31/2012	01/08/2020	01/14/2020
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #2327	931 LOMAS SANTA FE DR	SOLANA BEACH	CA	92075	12/31/2012	12/31/2012	10/11/2017	10/18/2017
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #2784	515 WEST WASHINGTON ST.	SAN DIEGO	CA	92103	07/17/2013	10/01/2013	07/01/2023	07/19/2023
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #2012	7788 REGENTS ROAD	SAN DIEGO	CA	92122	10/22/2013	01/01/2014	07/01/2023	07/19/2023
Contract Detail	THE VONS COMPANIES INC	PAVILIONS PHARMACY #2119	3850 VALLEY CENTRE DRIVE	SAN DIEGO	CA	92130-2331	10/22/2013	01/01/2014	07/28/2016	07/12/2017
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #2358	3610 ADAMS AVENUE	SAN DIEGO	CA	92116	10/22/2013	01/01/2014	05/15/2019	05/28/2019
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #2065	6951 EL CAMINO REAL	CARLSBAD	CA	92009	01/16/2014	04/01/2014	07/28/2016	07/12/2017
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #2107	10675 SCRIPPS POWAY PARKWAY	SAN DIEGO	CA	92131	01/16/2014	04/01/2014	10/11/2017	10/18/2017
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #2345	1000 WEST EL NORTE PARKWAY	ESCONDIDO	CA	92026	01/16/2014	04/01/2014	07/28/2016	07/12/2017
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #2355	4145 30TH STREET	SAN DIEGO	CA	92104	04/25/2014	07/01/2014	10/08/2021	10/25/2021
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #4018	10016 SCRIPPS RANCH BOULEVARD	SAN DIEGO	CA	92131	01/14/2015	04/01/2015	10/11/2017	10/18/2017
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #2081	13255 BLACK MOUNTAIN ROAD	SAN DIEGO	CA	92129	01/14/2015	04/01/2015	10/11/2017	10/18/2017
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #2144	262 NORTH EL CAMINO REAL	ENCINITAS	CA	92024	01/14/2015	04/01/2015	07/28/2016	07/12/2017
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #3044	1201 AVOCADO AVENUE	EL CAJON	CA	92020	07/05/2017	10/01/2017	10/11/2017	10/18/2017
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #2406	750 NORTH IMPERIAL AVENUE	EL CENTRO	CA	92243	07/19/2017	10/01/2017	10/11/2017	10/18/2017
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #2115	620 DENNERY ROAD	SAN DIEGO	CA	92154	07/19/2017	10/01/2017	10/11/2017	10/18/2017
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #1897	9643 MISSION GORGE ROAD	SANTEE	CA	92071	07/19/2017	10/01/2017	10/11/2017	10/18/2017
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #2079	11986 BERNARDO PLAZA	RANCHO BERNARDO	CA	92128	07/19/2017	10/01/2017	10/11/2017	10/18/2017
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #2360	845 COLLEGE BOULEVARD	OCEANSIDE	CA	92057	07/19/2017	10/01/2017	10/11/2017	10/18/2017
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #2118	3550 MURPHY CANYON ROAD	SAN DIEGO	CA	92123	07/19/2017	10/01/2017	10/11/2017	10/18/2017
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #2344	351 WEST FELICITA AVENUE HWY 395	ESCONDIDO	CA	92025	07/19/2017	10/01/2017	10/11/2017	10/18/2017
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #2735	2495 TRUXTON ROAD, SUITE 100	SAN DIEGO	CA	92106	07/19/2017	10/01/2017	10/11/2017	10/18/2017
Contract Detail	THE VONS COMPANIES INC	VONS PHARMACY #2071	2250 OTAY LAKES ROAD	CHULA VISTA	CA	91915	07/19/2017	10/01/2017	10/11/2017	10/18/2017
Contract Detail	THRIFTY PAYLESS INC.	RITE AID #5643	427 C STREET SUITE 100	SAN DIEGO	CA	92101	07/05/2016	10/01/2016	06/19/2018	07/20/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5644	535 ROBINSON AVENUE	SAN DIEGO	CA	92103	04/11/2013	07/01/2013	02/15/2024	03/07/2024
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5649	6939 LINDA VISTA ROAD	SAN DIEGO	CA	92111	04/11/2013	07/01/2013	05/04/2018	05/17/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5658	4077 GOVERNOR DRIVE	SAN DIEGO	CA	92122	04/11/2013	07/01/2013	07/01/2023	07/19/2023
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5660	10631 TIERRASANTA BOULEVARD	SAN DIEGO	CA	92124	04/11/2013	07/01/2013	07/01/2023	07/19/2023
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5654	3081-B CLAIREMONT DRIVE	SAN DIEGO	CA	92117	07/05/2016	10/01/2016	04/15/2019	04/26/2019
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5666	3515 DELMAR HEIGHTS ROAD	SAN DIEGO	CA	92130	07/05/2016	10/01/2016	08/14/2017	08/14/2017
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5652	3650 ADAMS AVENUE	SAN DIEGO	CA	92116	07/05/2016	10/01/2016	07/01/2023	07/19/2023
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5647	4840 NIAGARA AVENUE	SAN DIEGO	CA	92107	07/05/2016	10/01/2016	05/04/2018	05/17/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5620	661 SWEETWATER ROAD	SPRING VALLEY	CA	91977	07/05/2016	10/01/2016	08/14/2017	08/14/2017
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5618	7224 BROADWAY	LEMON GROVE	CA	91945	07/05/2016	10/01/2016	07/01/2023	07/19/2023
Contract Detail	UCSD-SDCC RETAIL PHARMACY	1200 GARDEN VIEW RD STE 103		ENCINITAS	CA	92024-2477	01/16/2014	04/01/2014	07/01/2018	07/01/2018
Contract Detail	VONS PHARMACY # 4902	330 LEWIS STREET	2ND FLOOR	SAN DIEGO	CA	92103	01/16/2014	04/01/2014	10/11/2017	10/18/2017
Contract Detail	VONS PHARMACY # 4901		9350 CAMPUS POINT DRIVE	LA JOLLA	CA	92037	01/16/2014	04/01/2014	12/05/2016	07/12/2017
Contract Detail	WALGREEN CO	DBA: WALGREENS #09433	3752 MISSION AVE	OCEANSIDE	CA	92058	12/19/2012	01/01/2013		07/12/2017
Contract Detail	WALGREEN CO	DBA: WALGREENS #07751	3507 CANNON RD	OCEANSIDE	CA	92056-4977	12/19/2012	01/01/2013	08/10/2017	08/14/2017
Contract Detail	WALGREEN CO	DBA: WALGREENS #12143	5504 BALBOA AVE	SAN DIEGO	CA	92111	12/19/2012	01/01/2013	08/10/2017	08/14/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05455	111 W WASHINGTON AVE	ESCONDIDO	CA	92025	12/19/2012	01/01/2013	08/10/2017	08/14/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06255	621 I STREET	CHULA VISTA	CA	91910	12/19/2012	01/01/2013	04/22/2019	04/26/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05700	1574 E VALLEY PKWY	ESCONDIDO	CA	92027	12/19/2012	01/01/2013	08/10/2017	08/14/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05844	215 NORTH 2ND STREET	EL CAJON	CA	92021	12/19/2012	01/01/2013		07/12/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05456	1510 N SANTA FE AVE	VISTA	CA	92083	12/19/2012	01/01/2013		07/12/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06222	802 S SANTA FE AVE	VISTA	CA	92084-6107	12/19/2012	01/01/2013	08/10/2017	08/14/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06094	3005 MIDWAY DRIVE	SAN DIEGO	CA	92110-4502	12/19/2012	01/01/2013		07/12/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07867	1430 EASTLAKE PKWY	CHULA VISTA	CA	91915	12/19/2012	01/01/2013		07/12/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07869	885 EUCLID AVE	NATIONAL CITY	CA	91950	12/19/2012	01/01/2013	08/10/2017	08/14/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07176	8766 NAVAJO RD	SAN DIEGO	CA	92119-2722	12/19/2012	01/01/2013		07/12/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02623	1111 THIRD AVE	CHULA VISTA	CA	91911-3105	12/19/2012	01/01/2013	08/10/2017	08/14/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 10142	460 W FELICITA AVENUE	ESCONDIDO	CA	92025-6518	12/19/2012	01/01/2013	08/10/2017	08/14/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09389	310 SYCAMORE AVENUE	VISTA	CA	92083-7702	12/19/2012	01/01/2013	06/01/2024	06/11/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06656	3222 UNIVERSITY AVENUE	SAN DIEGO	CA	92104-2010	12/19/2012	01/01/2013	12/01/2023	12/14/2023
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #13434	640 UNIVERSITY AVE	SAN DIEGO	CA	92103	12/19/2012	01/01/2013		07/12/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #09817	9305 MISSION GORGE RD	SANTEE	CA	92071-3815	12/19/2012	01/01/2013	08/10/2017	08/14/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11654	10787 CAMINO RUIZ	SAN DIEGO	CA	92126-2304	12/19/2012	01/01/2013		07/12/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11990	9728 WINTER GARDENS BLVD	LAKESIDE	CA	92040	12/19/2012	01/01/2013	08/10/2017	08/14/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11653	1320 ENCINITAS BLVD	ENCINITAS	CA	92024	12/19/2012	01/01/2013	08/10/2017	08/14/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12421	13390 POWAY RD	POWAY	CA	92064	12/19/2012	01/01/2013	04/22/2019	04/26/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS #13161	4029 43RD ST. STE 700	SAN DIEGO	CA	92105	12/19/2012	01/01/2013		07/12/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15388	301 UNIVERSITY AVE	SAN DIEGO	CA	92103	10/22/2013	01/01/2014		07/12/2017
Contract Detail	WALGREEN CO.	DBA: COMMUNITY A WALGREENS PHARMACY	3900 FIFTH AVENUE SUITE 110	SAN DIEGO	CA	92103	04/28/2014	07/01/2014	07/08/2015	07/12/2017
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16490	4130 LA JOLLA VILLAGE DR STE 103	LA JOLLA	CA	92037	07/18/2018	10/01/2018		10/01/2018
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	04/11/2013	07/01/2013	07/06/2015	07/12/2017
Contract Detail	WALGREENS MAIL SERVICE, INC.		8337 S PARK CIRCLE	ORLANDO	FL	32819-9049	04/11/2013	07/01/2013	07/06/2015	07/12/2017
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	07/13/2020	10/01/2020		10/01/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	07/13/2020	10/01/2020		10/01/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/13/2020	10/01/2020		10/01/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	07/13/2020	10/01/2020	10/15/2021	10/25/2021
Contract Detail	WELLPARTNER, INC	20800 SW 115TH AVE	SUITE 100	TUALATIN	OR	97062	08/20/2012	08/20/2012	08/12/2017	08/14/2017
Contract Detail	WESTERN PHARMACY GROUP LLC	DBA MEDICAL CENTER PHARMACY	340 4TH AVE STE 1	CHULA VISTA	CA	91910-3882	03/09/2018	03/09/2018	10/01/2022	10/14/2022
Contract Detail	WESTERN PHARMACY GROUP LLC	DBA MEDICAL CENTER PHARMACY	480 4TH AVE STE 100	CHULA VISTA	CA	91910-4411	03/09/2018	03/09/2018	01/08/2020	01/14/2020
Contract Detail	WESTERN PHARMACY GROUP LLC	DBA MEDICAL CENTER PHARMACY	3904 PARK BLVD	SAN DIEGO	CA	92103-3502	03/09/2018	03/09/2018	10/01/2022	10/14/2022
Contract Detail	WESTERN PHARMACY GROUP LLC	DBA MEDICAL CENTER PHARMACY	4074 FAIRMOUNT AVE	SAN DIEGO	CA	92105-1608	03/09/2018	03/09/2018	01/08/2020	01/14/2020
Contract Detail	WESTERN PHARMACY GROUP LLC	DBA GALLOWAY'S MEDICAL CENTER PHARMACY	2995 NATIONAL AVE	SAN DIEGO	CA	92113-2419	03/09/2018	03/09/2018	10/01/2022	10/14/2022
Contract Detail	WESTERN PHARMACY GROUP LLC	DBA COMMUNITY MEDICAL CENTER PHARMACY	610 GATEWAY CENTER WAY SUITES A--E	SAN DIEGO	CA	92102	03/09/2018	03/09/2018	10/01/2022	10/14/2022

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
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/14/2025 6:01 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1184722779	2/14/2025 6:01 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		RI	2/14/2025 6:01 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1184722779	2/14/2025 6:01 PM
Medicaid Billing	NPI: State	Insert	Change Request		RI	2/14/2025 6:01 PM
Addresses	Shipping Address	Insert	Change Request		UCSD East Campus Medical Center Pharmacy 6655 Alvarado Rd San Diego, CA 92120	1/22/2025 11:53 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	110027530A (MA)		8/27/2024 2:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/27/2024 2:06 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		110027530D	8/27/2024 2:06 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MA	8/27/2024 2:06 PM
Details	Last Recertification Date	Update	Recertification	8/29/2023 2:33:09 PM	8/27/2024 2:06:21 PM	8/27/2024 2:06 PM
Contacts	Primary Contact	Update	Profile Change Request	Tolentino, Katrina 340B Regulatory and Compliance Specialist UCSD Medical Center 6195433104	Tolentino, Katrina 340B Program Coordinator UCSD Medical Center 6195433104	8/13/2024 1:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/11/2024 10:57 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1184722779	6/11/2024 10:57 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	6/11/2024 10:57 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1184722779	6/11/2024 10:57 AM
Medicaid Billing	NPI: State	Insert	Change Request		VA	6/11/2024 10:57 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	300047829 (IN)		3/7/2024 11:35 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/7/2024 11:35 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		30085399	3/7/2024 11:35 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	3/7/2024 11:35 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1004402 (WA)		12/14/2023 5:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/14/2023 5:02 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2261049	12/14/2023 5:02 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	12/14/2023 5:02 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	000131495 (NM)		8/29/2023 2:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2023 2:33 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		000B1495	8/29/2023 2:33 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NM	8/29/2023 2:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2023 2:33 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		115505500	8/29/2023 2:33 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	8/29/2023 2:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2023 2:33 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		536005	8/29/2023 2:33 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		HI	8/29/2023 2:33 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	090444900 (FL)		8/29/2023 2:33 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	8/29/2023 2:33 PM
Medicaid Billing	NPI: State	Insert	Recertification		HI	8/29/2023 2:33 PM
Details	Last Recertification Date	Update	Recertification	9/8/2022 4:03:41 PM	8/29/2023 2:33:09 PM	8/29/2023 2:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/14/2023 5:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3818434	6/14/2023 5:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	6/14/2023 5:08 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1184722779	6/14/2023 5:08 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	6/14/2023 5:08 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1184722779 (CT)		3/15/2023 10:15 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	30047829 (IN)		3/15/2023 10:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2023 10:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		309479	3/15/2023 10:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	3/15/2023 10:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2023 10:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003127322	3/15/2023 10:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	3/15/2023 10:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2023 10:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1184722779	3/15/2023 10:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	3/15/2023 10:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2023 10:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300047829	3/15/2023 10:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	3/15/2023 10:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2023 10:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		30003889620001	3/15/2023 10:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		KS	3/15/2023 10:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2023 10:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		112752403	3/15/2023 10:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	3/15/2023 10:15 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	021303 (AZ)		3/15/2023 10:15 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	200441140C (KS)		3/15/2023 10:15 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1184722779 (TX)		3/15/2023 10:15 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1184722779	3/15/2023 10:15 AM
Medicaid Billing	NPI: State	Insert	Change Request		ID	3/15/2023 10:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/15/2022 12:23 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		01200377	12/15/2022 12:23 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	12/15/2022 12:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/15/2022 12:23 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3137541	12/15/2022 12:23 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NH	12/15/2022 12:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1184722779	12/15/2022 12:23 PM
Medicaid Billing	NPI: State	Insert	Change Request		NH	12/15/2022 12:23 PM
Addresses	Shipping Address	Insert	Change Request		UCSD Specialty Pharmacy 9610 Ridgehaven Ct Ste C San Diego, CA 92123-5603	11/1/2022 1:55 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1417670688	11/1/2022 1:55 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	11/1/2022 1:55 PM
Details	Last Recertification Date	Update	Recertification	9/2/2021 6:03:24 PM	9/8/2022 4:03:41 PM	9/8/2022 4:03 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/15/2022 4:39 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		41578000	7/15/2022 4:39 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	7/15/2022 4:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/15/2022 4:39 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10026299201	7/15/2022 4:39 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	7/15/2022 4:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/15/2022 4:39 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000788675	7/15/2022 4:39 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	7/15/2022 4:39 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1184722779	7/15/2022 4:39 PM
Medicaid Billing	NPI: State	Insert	Change Request		MD	7/15/2022 4:39 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1184722779	7/15/2022 4:39 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	7/15/2022 4:39 PM
Addresses	Shipping Address	Update	Change Request	UCSD Moores Cancer Center 3855 Health Science Drive #0845 La Jolla, CA 92093	UCSD Moores Cancer Center 3855 Health Science Drive RM 1036 La Jolla, CA 92093	1/18/2022 7:09 AM
Contacts	Primary Contact	Update	Change Request	Sharma, Amar 340B Program Coordinator UCSD Medical Center 6195432528	Tolentino, Katrina 340B Regulatory and Compliance Specialist UCSD Medical Center 6195433104	12/6/2021 3:49 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/12/2021 10:31 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1004402	10/12/2021 10:31 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	10/12/2021 10:31 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/12/2021 10:31 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		016210007	10/12/2021 10:31 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	10/12/2021 10:31 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1184722779 (ID)		10/12/2021 10:31 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1184722779 (ID)		10/12/2021 10:31 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1184722779	10/12/2021 10:31 AM
Medicaid Billing	NPI: State	Insert	Change Request		WA	10/12/2021 10:31 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1184722779	10/12/2021 10:31 AM
Medicaid Billing	NPI: State	Insert	Change Request		MO	10/12/2021 10:31 AM
Details	Last Recertification Date	Update	Recertification	9/2/2020 2:22:27 PM	9/2/2021 6:03:24 PM	9/2/2021 6:03 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1707040 (LA)		7/22/2021 11:52 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/22/2021 11:52 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		UCS0025N	7/22/2021 11:52 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AL	7/22/2021 11:52 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/22/2021 11:52 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1509192	7/22/2021 11:52 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	7/22/2021 11:52 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1184722779 (LA)		7/22/2021 11:52 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1184722779	7/22/2021 11:52 AM
Medicaid Billing	NPI: State	Insert	Change Request		AL	7/22/2021 11:52 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1184722779	7/22/2021 11:52 AM
Medicaid Billing	NPI: State	Insert	Change Request		TN	7/22/2021 11:52 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1184722779	7/22/2021 11:52 AM
Medicaid Billing	NPI: State	Insert	Change Request		MS	7/22/2021 11:52 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1184722779 (AL)		4/28/2021 9:33 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	41578000 (MD)		4/28/2021 9:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/28/2021 9:33 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1707040	4/28/2021 9:33 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	4/28/2021 9:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/28/2021 9:33 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		30047829	4/28/2021 9:33 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	4/28/2021 9:33 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1184722779 (DC)		4/28/2021 9:33 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2002014 (NH)		4/28/2021 9:33 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1184722779 (AL)		4/28/2021 9:33 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1184722779 (DC)		4/28/2021 9:33 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1184722779 (MD)		4/28/2021 9:33 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1184722779 (NH)		4/28/2021 9:33 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1184722779	4/28/2021 9:33 AM
Medicaid Billing	NPI: State	Insert	Change Request		LA	4/28/2021 9:33 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1184722779	4/28/2021 9:33 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	4/28/2021 9:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/4/2021 1:05 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1184722779	2/4/2021 1:05 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	2/4/2021 1:05 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/4/2021 1:05 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110027530A	2/4/2021 1:05 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	2/4/2021 1:05 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1184722779	2/4/2021 1:05 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	2/4/2021 1:05 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1184722779	2/4/2021 1:05 PM
Medicaid Billing	NPI: State	Insert	Change Request		MA	2/4/2021 1:05 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	200042370A (IN)		9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1707040 (LA)		9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	016210007 (MO)		9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	118997200 (WY)		9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		41578000	9/2/2020 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MD	9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MT	9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		000131495	9/2/2020 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NM	9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		SD	9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	139656105 (AR)		9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	01200377 (KY)		9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	110027530A (MA)		9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	0574678 (MT)		9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	10026299201 (NE)		9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	000B1495 (NM)		9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1184722779 (NC)		9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1509192 (TN)		9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1184722779 (VA)		9/2/2020 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1004402 (WA)		9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		AK	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		AL	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		DC	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		DE	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		ID	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		KS	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		MD	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		ME	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		MT	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		NH	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		NV	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		SD	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		VT	9/2/2020 2:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1184722779	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/2/2020 2:22 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/2/2020 2:22 PM
Details	Last Recertification Date	Update	Recertification	8/21/2019 12:11:47 PM	9/2/2020 2:22:27 PM	9/2/2020 2:22 PM
Details	Last Recertification Date	Update	Recertification	8/22/2018 4:37:53 PM	8/21/2019 12:11:47 PM	8/21/2019 12:11 PM
Addresses	Shipping Address	Insert	Change Request		UCSD Outpatient Pavilion Pharmacy 9400 Campus Point Drive Room 3-400A La Jolla, CA 92037	3/27/2019 6:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1184722779	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AL	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1005640	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AK	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1184722779	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		200042370A	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1707040	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1184722779	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		ME	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		016210007	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0050025	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		VT	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		118997200	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WY	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	PHB034810 (CA)		11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	1184722779	250467504	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	039945500	1184722779	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	807816300	1184722779	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	1184722779	0548636	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	200441140A	200441140C	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	415780000 (MD)		11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	15924284	110027530A	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	1184722779	0574678	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	10025548200	10026299201	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	001188547	1184722779	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0193488 (NJ)		11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	B1495	000B1495	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	9500025	1184722779	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1009899940001 (PA)		11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0900001 (RI)		11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	11277A	11781B	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	112752403	1184722779	11/20/2018 11:38 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	3025822	1004402	11/20/2018 11:38 AM
Details	Last Recertification Date	Update	Recertification	11/29/2017 12:58:00 PM	8/22/2018 4:37:53 PM	8/22/2018 4:37 PM
Addresses	Shipping Address	Insert	Change Request		UCSD-SDCC Retail Pharmacy 1200 Garden View Road Suite 103 Encinitas, CA 92024	7/2/2018 12:14 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1518300532	6/27/2018 3:41 PM
Contacts	Primary Contact	Update	Change Request	Kulischak, Danielle Pharmacy Purchasing Coordinator UCSD Medical Center 6195436381	Sharma, Amar 340B Program Coordinator UCSD Medical Center 6195432528	5/9/2018 1:34 PM
Addresses	Shipping Address	Insert	Change Request		SAFECOR/ UCSD MEDICAL CENTER 4060 BUSINESS PARK DRIVE SUITE B COLUMBUS, OH 43204	1/4/2018 2:23 PM
Addresses	Shipping Address	Insert	Recertification		UCSD Home Infusion Pharmacy 9610 Ridgehaven Court Suite A San Diego, CA 92123	11/29/2017 12:58 PM
Addresses	Shipping Address	Insert	Recertification		UCSD Moores Cancer Center 3855 Health Science Drive #0845 La Jolla, CA 92093	11/29/2017 12:58 PM
Details	Last Recertification Date	Update	Recertification	8/12/2016 12:00:00 AM	11/29/2017 12:58:00 PM	11/29/2017 12:58 PM
Contacts	Authorizing Official	Update		Donaldson, Lori CFO 6195436613	Donaldson, Lori CFO UCSD Medical Center 6195436613	10/4/2017 12:00 PM
Contacts	Primary Contact	Update		Kulischak, Danielle Pharmacy Purchasing Coordinator 6195436381	Kulischak, Danielle Pharmacy Purchasing Coordinator UCSD Medical Center 6195436381	9/22/2017 3:44 PM
Contacts	Authorizing Official	Update		HOGAN, ROBERT CFO 6195436060	Donaldson, Lori CFO 6195436613	8/14/2017 6:58 PM
Contacts	Primary Contact	Insert			Kulischak, Danielle Pharmacy Purchasing Coordinator 6195436381	7/12/2017 5:02 PM
Addresses	Shipping Address	Delete		UCSD Home Infusion Pharmacy 9610 Ridgehaven Court San Diego, CA 92123		7/12/2017 5:02 PM
Addresses	Shipping Address	Delete		UCSD Moores Cancer Center 3855 Health Science Drive La Jolla, CA 92093		7/12/2017 5:02 PM
Addresses	Main Address	Insert			200 WEST ARBOR DRIVE SAN DIEGO, CA 92103	7/12/2017 5:02 PM
Addresses	Shipping Address	Insert			UCSD Medical Offices South Pharmacy 4168 Front Street San Diego, CA 92103	7/12/2017 5:02 PM
Addresses	Shipping Address	Insert			UCSD Home Infusion Pharmacy 9610 Ridgehaven Court San Diego, CA 92123	7/12/2017 5:02 PM
Addresses	Shipping Address	Insert			UCSD Moores Cancer Center 3855 Health Science Drive La Jolla, CA 92093	7/12/2017 5:02 PM
Addresses	Shipping Address	Insert			The John M & Sally B Thornton Hospital 9300 Campus Point Dr Rm LL-463 La Jolla, CA 92037	7/12/2017 5:02 PM
Addresses	Shipping Address	Insert			UCSD SDCC Infusion Pharmacy 1200 Garden View Rd Ste 200 Encinitas, CA 92024	7/12/2017 5:02 PM
Addresses	Shipping Address	Insert			UCSD Health La Jolla Jacobs Med Center & Sulpizio Cardiovascular Center 9300 Campus Point Drive La Jolla, CA 92037	7/12/2017 5:02 PM
Addresses	Shipping Address	Insert			UCSD Medical Center Pharmacy 200 West Arbor Drive Room I317 San Diego, CA 92103-8765	7/12/2017 5:02 PM
Details	Last Recertification Date	Update		8/14/2015 12:00:00 AM	8/12/2016 12:00:00 AM	8/12/2016 4:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			021303	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			AZ	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			139656105	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			AR	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			02328542	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			CO	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			1184722779	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			DE	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			039945500	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			DC	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			090444900	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			FL	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			000157495X	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			GA	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			807816300	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			ID	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			330599494001	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			IL	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			1184722779	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			IA	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			200441140A	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			KS	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			01200377	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			KY	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			415780000	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			MD	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			15924284	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			MA	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			1184722779	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			MI	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			1184722779	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			MN	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			1184722779	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			MT	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			10025548200	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			NE	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			001188547	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			NV	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			2002014	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			NH	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			0193488	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			NJ	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			B1495	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			NM	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			02913739	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			NY	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			9500025	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			NC	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			7673405	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			OH	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			100690800A	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			OK	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			297530	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			OR	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			1009899940001	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			PA	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			0900001	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			RI	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			11277A	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			SC	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			1509192	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			TN	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			112752403	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			TX	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			1184722779	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			UT	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			1184722779	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			VA	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			3025822	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			WA	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Number	Insert			81008100	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: State	Insert			WI	3/4/2016 5:14 PM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	8/14/2015 4:27 PM
Details	Last Recertification Date	Update		8/28/2014 12:00:00 AM	8/14/2015 12:00:00 AM	8/14/2015 4:27 PM
Details	Last Recertification Date	Update		8/28/2013 12:00:00 AM	8/28/2014 12:00:00 AM	8/28/2014 7:49 AM
Contacts	Authorizing Official	Insert			HOGAN, ROBERT CFO 6195436060	7/3/2014 4:20 PM
Details	State	Update		Terminated	Active	4/14/2014 12:24 PM
Terminations	Termination Comments	Update		Child site terminated as the request of the parent because it does not purchase under the 340B program		4/14/2014 12:24 PM
Terminations	Termination Date	Update		7/1/2014 12:00:00 AM		4/14/2014 12:24 PM
Terminations	Termination Reason	Update		Other		4/14/2014 12:24 PM
Details	Comments Public	Insert			4/10/2014 - Multiple terminations/reinstatements recorded in error; site remained continuously eligible from participation start date. 10/21/09 ADDED MEDICAID#	4/14/2014 12:24 PM
Details	State	Update		Active	Terminated	4/2/2014 7:13 AM
Terminations	Termination Comments	Update			Child site terminated as the request of the parent because it does not purchase under the 340B program	4/2/2014 7:13 AM
Terminations	Termination Date	Update			7/1/2014 12:00:00 AM	4/2/2014 7:13 AM
Terminations	Termination Reason	Update			Other	4/2/2014 7:13 AM
Details	State	Update		Terminated	Active	3/31/2014 12:59 PM
Terminations	Termination Comments	Update		This site does not purchase 340B drugs.		3/31/2014 12:59 PM
Terminations	Termination Date	Update		4/1/2014 12:00:00 AM		3/31/2014 12:59 PM
Terminations	Termination Reason	Update		Other		3/31/2014 12:59 PM
Details	Comments Public	Insert			10/21/09 ADDED MEDICAID# 03/25/2014: Termination recorded in error; site remained continuously eligible from participation start date.	3/31/2014 12:59 PM
Details	State	Update		Active	Terminated	3/25/2014 2:42 PM
Terminations	Termination Comments	Update			This site does not purchase 340B drugs.	3/25/2014 2:42 PM
Terminations	Termination Date	Update			4/1/2014 12:00:00 AM	3/25/2014 2:42 PM
Terminations	Termination Reason	Update			Other	3/25/2014 2:42 PM
Medicaid Billing	NPI: Number	Insert			1013359462	12/10/2013 8:36 AM
Medicaid Billing	NPI: Number	Insert			1184722779	12/10/2013 8:36 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/28/2013 12:00:00 AM	8/28/2013 6:51 AM
Medicaid Billing	NPI: Number	Insert			1598786576	5/14/2012 8:09 AM
Medicaid Billing	NPI: Number	Insert			1316968399	5/14/2012 8:09 AM
Medicaid Billing	NPI: Number	Insert			1952322935	5/14/2012 8:09 AM
Medicaid Billing	NPI: Number	Insert			1730273582	5/14/2012 8:09 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/14/2012 8:09 AM
Details	Entity Name	Update		UCSD	UCSD MEDICAL CENTER	3/22/2012 8:58 AM
Details	Entity Subname	Update		MEDICAL CENTER		3/22/2012 8:58 AM
Medicaid Billing	Medicaid: Is Primary	Insert			True	10/30/2007 5:01 PM
Medicaid Billing	Medicaid: Number	Insert			PHB034810	10/30/2007 5:01 PM
Medicaid Billing	Medicaid: State	Insert			CA	10/30/2007 5:01 PM
Details	Last Recertification Date	Insert				10/30/2007 5:01 PM
Details	Grant Number	Insert				10/30/2007 5:01 PM
Details	340B ID	Insert			DSH050025	10/30/2007 5:01 PM
Details	Is Authorizing Official EHB Data	Insert				10/30/2007 5:01 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/30/2007 5:01 PM
Details	Medicare Provider Number	Insert			050025	10/30/2007 5:01 PM
Details	Entity Name	Insert			UCSD	10/30/2007 5:01 PM
Details	Program Code	Insert			DSH	10/30/2007 5:01 PM
Details	Entity Subname	Insert			MEDICAL CENTER	10/30/2007 5:01 PM
Dates	Participating Approval Date	Insert			10/30/2007 12:00:00 AM	10/30/2007 5:01 PM
Details	State	Insert			Active	10/30/2007 5:01 PM
Dates	Registration Date	Insert			10/30/2007 12:00:00 AM	10/30/2007 5:01 PM
Dates	Signed By Date	Insert				10/30/2007 5:01 PM
Dates	Start Date	Insert			12/1/1992 12:00:00 AM	10/30/2007 5:01 PM
Terminations	Termination Comments	Insert				10/30/2007 5:01 PM
Terminations	Termination Date	Insert				10/30/2007 5:01 PM
Terminations	Termination Effective Date	Insert				10/30/2007 5:01 PM
Terminations	Termination Reason	Insert				10/30/2007 5:01 PM
Details	Comments Public	Insert			10/21/09 ADDED MEDICAID#	10/30/2007 5:01 PM