Contract Pharmacy Details

WALGREEN CO.
DSH050025 UCSD MEDICAL CENTER

Covered Entity Details

Entity Name

UCSD MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH050025

Entity Address

200 WEST ARBOR DRIVE
SAN DIEGO, CA 92103

Medicare Provider Number

050025

Participating Start Date

12/1/1992

Last Recertification Date

8/27/2024

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA WALGREENS SPECIALTY PHARMACY #16490
4130 LA JOLLA VILLAGE DR STE 103
LA JOLLA, CA 92037

Pharmacy Comments

Contract Details

Approval Date

7/18/2018

Contract Begin Date

10/1/2018

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Lori Donaldson, CFO
(619) 543-6613

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

7/18/2018

340B Drug Pricing Program Database