Covered Entity Details

DSH050262H RONALD REAGAN UCLA MEDICAL CENTER (Active) - information as of 4/29/2025 12:35:34 AM

Main Details

Name

RONALD REAGAN UCLA MEDICAL CENTER

Subdivision Name

Bowyer Oncology Clinic

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050262H

Medicare Provider Number

050262

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

5/12/2012

Participating Start Date

7/1/2012

Participating Approval Date

6/26/2012

Last Recertification Date

8/16/2024

Contacts

Authorizing Official

UCLA Health
Tammy Wallace, Chief Financial Officer Hospital System
(310) 794-8627

Primary Contact

UCLA
Lana Balderrama, 340B Program Supervisor
(310) 267-1278

Addresses

Street Address

200 Medical Plaza, Suite 120
Los Angeles, CA 90095

Billing Address

Ronald Reagan Medical Center
200 Medical Plaza
Suite 120
Los Angeles, CA 90095

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	HSC30262W	1902803315

Shipping Addresses

Shipping Address 1

Ronald Reagan UCLA Medical Center
662 Gayley Avenue, Room B504A
Los Angeles, CA 90095

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
DSH050262AA	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Radiology CT - Outpatient	200 Medical Plaza, Suite B165-50	Los Angeles	CA	Active
DSH050262AB	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Clinical & Translational Research Center	10833 Le Conte Ave, Suite BE-144	Los Angeles	CA	Terminated
DSH050262AC	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Dermatology Clinic	200 Medical Plaza Suite 450	Los Angeles	CA	Active
DSH050262AD	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Dermatology Surgery	200 Medical Plaza, Suite 465	Los Angeles	CA	Active
DSH050262AE	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Doris Stein Retina Clinic	200 Stein Plaza, Room 1-533	Los Angeles	CA	Active
DSH050262AF	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Family Medicine Clinic	200 Medical Plaza, Suite 440	Los Angeles	CA	Active
DSH050262AG	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Gonda Diabetes Center	200 Medical Plaza, Suite 530	Los Angeles	CA	Active
DSH050262AH	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Hemapheresis Unit	200 Medical Plaza, Suite 670	Los Angeles	CA	Active
DSH050262AJ	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Hyperbaric Center	200 Medical Plaza, Suite B270	Los Angeles	CA	Active
DSH050262AK	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Internal Medicine Clinic	200 Medical Plaza, Suite 420	Los Angeles	CA	Active
DSH050262AL	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Medical Specialties Suite	200 Medical Plaza, Suite 365	Los Angeles	CA	Active
DSH050262AM	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Pediatric Heart Center	200 Medical Plaza, Suite 330	Los Angeles	CA	Active
DSH050262AN	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Medical Procedures Unit	200 Medical Plaza, Suite 320	Los Angeles	CA	Active
DSH050262AP	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Radiology MRI- Outpatient	100 Medical Plaza, Suite 100	Los Angeles	CA	Active
DSH050262AQ	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Radiology MRI - Outpatient	200 Medical Plaza, Suite B165	Los Angeles	CA	Active
DSH050262AR	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Neurophysiology - EEG	300 Medical Plaza, Suite 2100	Los Angeles	CA	Active
DSH050262AS	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Nuclear Medicine Clinic	200 Medical Plaza, Suite B-114	Los Angeles	CA	Active
DSH050262AT	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Sleep Disorder Clinic	10833 Le Conte Ave	Los Angeles	CA	Active
DSH050262AU	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Wound Care Center	200 Medical Plaza, Suite 528	Los Angeles	CA	Active
DSH050262AV	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Pediatrics Infusion Center	200 Medical Plaza, Suite 265	Los Angeles	CA	Active
DSH050262AW	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Connie Frank Kidney Transplant Center	200 Medical Plaza, Room 565	Los Angeles	CA	Active
DSH050262AX	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Thoracic Surgery, Surgical Oncology	200 Medical Plaza, Suite B265	Los Angeles	CA	Active
DSH050262AY	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Ronald Reagn UCLA Medical Center - CTRC - Research and Sleep Disorder	10833 Le Conte Avenue Suite BE-144	Los Angeles	CA	Active
DSH050262AZ	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Santa Clarita Radiation Oncology - Radiation Oncology	27235 Tourney Rd	Santa Clarita	CA	Active
DSH050262E	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Pulmonary Function Lab	200 Medical Plaza, Suite 302	Los Angeles	CA	Active
DSH050262EA	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Nuclear Medicine - Theranostics	100 Medical Plaza Suite 700	Los Angeles	CA	Active
DSH050262EB	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Internal Medicine - Immediate Care	200 Medical Plaza	Los Angeles	CA	Active
DSH050262EC	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Cardiovascular - Cardiology	100 Medical Plaza, Ste 700	Los Angeles	CA	Active
DSH050262F	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Eye and Laser OR at Stein Eye Institute with Laser Clinic	300 Stein Plaza	Los Angeles	CA	Active
DSH050262G	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Audiology Clinic	200 Medical Plaza, Suite 540	Los Angeles	CA	Active
DSH050262H	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Bowyer Oncology Clinic	200 Medical Plaza, Suite 120	Los Angeles	CA	Active
DSH050262J	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Radiation Oncology	200 Medical Plaza, Suite B265	Los Angeles	CA	Active
DSH050262K	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Radiology Outpatient General Diagnostic	200 Medical Plaza, Suite 165	Los Angeles	CA	Active
DSH050262L	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Rehabilitation - PT/OT	1000 Veteran Ave, Rm A-744	Los Angeles	CA	Active
DSH050262M	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Speech Pathology Clinic	200 Medical Plaza, Suite 540	Los Angeles	CA	Active
DSH050262N	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Surgery Center	200 Medical Plaza, Suite 660	Los Angeles	CA	Active
DSH050262P	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Pfleger Liver Clinic	100 Medical Plaza, Suite 700	Los Angeles	CA	Active
DSH050262Q	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Radiology - Ultrasound	100 Medical Plaza, Suite 100	Los Angeles	CA	Active
DSH050262R	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Radiology Ultrasound Pediatric	200 Medical Plaza, Suite 165	Los Angeles	CA	Active
DSH050262S	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	West Medical OB/GYN Clinic	1010 Veteran Ave, Level I	Los Angeles	CA	Active
DSH050262T	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Breast Imaging Clinic	200 Medical Plaza, Suite B170	Los Angeles	CA	Active
DSH050262U	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Women's Health Center	100 Medical Plaza, Suite 250	Los Angeles	CA	Active
DSH050262V	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Brachytherapy Clinic	200 Medical Plaza, Suite B265-40	Los Angeles	CA	Active
DSH050262W	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Cardiopulmonary Rehabilitation	100 Medical Plaza, Suite 440	Los Angeles	CA	Active
DSH050262X	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Cardiomyopathy Clinic	200 Medical Plaza, Suite 224	Los Angeles	CA	Terminated
DSH050262Y	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Radiology CT - Outpatient	100 Medical Plaza, Suite 100	Los Angeles	CA	Active
DSH050262Z	Child	DSH	RONALD REAGAN UCLA MEDICAL CENTER	Cardiovascular Cardiomyopathy Center	100 Medical Plaza, Suite 630	Los Angeles	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/16/2023 11:22:42 AM	8/16/2024 11:56:42 AM	8/16/2024 11:56 AM
Addresses	Shipping Address	Update	Change Request	Ronald Reagan UCLA Medical Center 662 Gayley Avenue, Room 504A Los Angeles, CA 90095	Ronald Reagan UCLA Medical Center 662 Gayley Avenue, Room B504A Los Angeles, CA 90095	11/6/2023 7:04 AM
Details	Last Recertification Date	Update	Recertification	9/8/2022 7:18:50 PM	8/16/2023 11:22:42 AM	8/16/2023 11:22 AM
Contacts	Primary Contact	Update	Group Change Request	MenMuir, Kerry Director of Inpatient Pharmacy Ronald Reagan UCLA Medical Center 3102678509	Balderrama, Lana 340B Program Supervisor UCLA 3102671278	5/16/2023 4:30 PM
Details	Last Recertification Date	Update	Recertification	8/27/2021 4:46:56 PM	9/8/2022 7:18:50 PM	9/8/2022 7:18 PM
Contacts	Authorizing Official	Update	AO Change Request	Staton, Paul CFO UCLA Medical Center 3102679308	Wallace, Tammy Chief Financial Officer Hospital System UCLA Health 3107948627	6/21/2022 6:27 AM
Addresses	Shipping Address	Delete	Recertification	UCLA Medical Plaza Level I Pharmacy 200 Medical Plaza, Suite 135 Los Angeles, CA 90095		8/27/2021 4:46 PM
Addresses	Shipping Address	Insert	Recertification		Ronald Reagan UCLA Medical Center 662 Gayley Avenue, Room 504A Los Angeles, CA 90095	8/27/2021 4:46 PM
Details	Last Recertification Date	Update	Recertification	8/18/2020 12:56:39 PM	8/27/2021 4:46:56 PM	8/27/2021 4:46 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	8/18/2020 12:56 PM
Details	Last Recertification Date	Update	Recertification	8/21/2019 11:48:23 AM	8/18/2020 12:56:39 PM	8/18/2020 12:56 PM
Contacts	Primary Contact	Update	Profile Change Request	Men Muir, Kerry Director of Inpatient Pharmacy Ronald Reagan UCLA Medical Center 3102678509	MenMuir, Kerry Director of Inpatient Pharmacy Ronald Reagan UCLA Medical Center 3102678509	12/5/2019 4:45 PM
Contacts	Primary Contact	Update	Profile Change Request	Men Muir, Kerry Interim Chief of Pharmacy Ronald Reagan UCLA Medical Center 3102678509	Men Muir, Kerry Director of Inpatient Pharmacy Ronald Reagan UCLA Medical Center 3102678509	12/4/2019 2:31 PM
Details	Last Recertification Date	Update	Recertification	8/16/2018 10:56:35 AM	8/21/2019 11:48:23 AM	8/21/2019 11:48 AM
Details	Last Recertification Date	Update	Recertification	11/13/2017 10:35:53 AM	8/16/2018 10:56:35 AM	8/16/2018 10:56 AM
Addresses	Billing Address	Update	Change Request	Ronald Reagan Medical Center File 2009 Los Angeles, CA 90074	Ronald Reagan Medical Center 200 Medical Plaza Suite 120 Los Angeles, CA 90095	12/15/2017 12:08 PM
Details	Last Recertification Date	Update	Recertification	9/1/2016 12:00:00 AM	11/13/2017 10:35:53 AM	11/13/2017 10:35 AM
Contacts	Primary Contact	Insert	Change Request		Men Muir, Kerry Interim Chief of Pharmacy Ronald Reagan UCLA Medical Center 3102678509	10/16/2017 1:05 PM
Contacts	Authorizing Official	Update		Staton, Paul CFO 3102679308	Staton, Paul CFO UCLA Medical Center 3102679308	10/10/2017 5:41 PM
Contacts	Signed By	Update		Staton, Paul CFO 3102679308	Staton, Paul CFO UCLA Medical Center 3102679308	10/10/2017 5:41 PM
Contacts	Authorizing Official	Insert			Staton, Paul CFO 3102679308	4/26/2017 10:13 AM
Contacts	Signed By	Insert			Staton, Paul CFO 3102679308	4/26/2017 10:13 AM
Addresses	Main Address	Insert			200 Medical Plaza, Suite 120 Los Angeles, CA 90095	4/26/2017 10:12 AM
Addresses	Billing Address	Insert			Ronald Reagan Medical Center File 2009 Los Angeles, CA 90074	4/26/2017 10:12 AM
Addresses	Shipping Address	Insert			UCLA Medical Plaza Level I Pharmacy 200 Medical Plaza, Suite 135 Los Angeles, CA 90095	4/26/2017 10:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/1/2016 8:51 AM
Medicaid Billing	Medicaid: Number	Insert			HSC30262W	9/1/2016 8:51 AM
Medicaid Billing	Medicaid: State	Insert			CA	9/1/2016 8:51 AM
Details	Last Recertification Date	Update		8/31/2015 12:00:00 AM	9/1/2016 12:00:00 AM	9/1/2016 8:51 AM
Details	Last Recertification Date	Update		8/28/2014 12:00:00 AM	8/31/2015 12:00:00 AM	9/1/2015 11:59 AM
Details	Last Recertification Date	Update		9/10/2013 8:18:51 PM	8/28/2014 12:00:00 AM	8/28/2014 3:58 PM
Details	Last Recertification Date	Update			9/10/2013 8:18:51 PM	9/10/2013 8:18 PM
Details	340B ID	Update		IS-JH-DSH050262H	DSH050262H	6/26/2012 2:25 PM
Dates	Participating Approval Date	Update			6/26/2012 12:00:00 AM	6/26/2012 2:25 PM
Details	State	Update		Pending	Active	6/26/2012 2:25 PM
Dates	Start Date	Update			7/1/2012 12:00:00 AM	6/26/2012 2:25 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	IS-JH-DSH050262H	6/6/2012 3:53 PM
Medicaid Billing	NPI: Number	Insert			1902803315	5/12/2012 7:17 PM
Details	Last Recertification Date	Insert				5/12/2012 7:17 PM
Details	Grant Number	Insert				5/12/2012 7:17 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	5/12/2012 7:17 PM
Details	Is Authorizing Official EHB Data	Insert				5/12/2012 7:17 PM
Dates	Last Date That 340B Drugs Purchased	Insert				5/12/2012 7:17 PM
Details	Medicare Provider Number	Insert			050262	5/12/2012 7:17 PM
Details	Entity Name	Insert			RONALD REAGAN UCLA MEDICAL CENTER	5/12/2012 7:17 PM
Details	Program Code	Insert			DSH	5/12/2012 7:17 PM
Details	Entity Subname	Insert			Bowyer Oncology Clinic	5/12/2012 7:17 PM
Dates	Participating Approval Date	Insert				5/12/2012 7:17 PM
Details	State	Insert			Pending	5/12/2012 7:17 PM
Dates	Registration Date	Insert			5/12/2012 12:00:00 AM	5/12/2012 7:17 PM
Dates	Signed By Date	Insert			5/12/2012 12:00:00 AM	5/12/2012 7:17 PM
Dates	Start Date	Insert				5/12/2012 7:17 PM
Terminations	Termination Comments	Insert				5/12/2012 7:17 PM
Terminations	Termination Date	Insert				5/12/2012 7:17 PM
Terminations	Termination Effective Date	Insert				5/12/2012 7:17 PM
Terminations	Termination Reason	Insert				5/12/2012 7:17 PM