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KROGER SPECIALTY PHARMACY INC
DSH050348 UCI MEDICAL CENTER
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Covered Entity Details
Entity Name
UCI MEDICAL CENTER
Subdivision Name
UNIVERSITY OF CALIFORNIA, IRVINE
Type
Disproportionate Share Hospital
340B ID
DSH050348
Entity Address
101 THE CITY DR. S RT32
ORANGE, CA 92868
Medicare Provider Number
050348
Participating Start Date
1/1/1998
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
KROGER SPECIALTY PHARMACY INC
Pharmacy Address
KROGER SPECIALTY PHARMACY CA 3
1821 KAISER AVE
IRVINE, CA 92614-5707
Pharmacy Comments
Contract Details
Approval Date
10/17/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/5/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Richard Gannotta, Chief Executive Officer
(714) 456-7830
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
10/17/2018
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