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BRIOVARX OF MAINE INC
DSH050262 RONALD REAGAN UCLA MEDICAL CENTER
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Covered Entity Details
Entity Name
RONALD REAGAN UCLA MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050262
Entity Address
757 WESTWOOD PLAZA
LOS ANGELES, CA 90095
Medicare Provider Number
050262
Participating Start Date
1/1/1998
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
BRIOVARX OF MAINE INC
Pharmacy Address
DBA BRIOVARX
53 DARLING AVE
SOUTH PORTLAND, ME 04106
Pharmacy Comments
Contract Details
Approval Date
7/9/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/8/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Paul Staton, CFO
(310) 267-9308
Contract Pharmacy Representative
Optum RX
Joseph Iovino, VP
(412) 445-4495
Signed By Date
7/9/2018
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