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KROGER SPECIALTY PHARMACY TX
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
KROGER SPECIALTY PHARMACY TX
Pharmacy Address
4280 KELLWAY CIR
ADDISON, TX 75001-4200
Pharmacy Comments
Contract Details
Approval Date
1/14/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/30/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
Paul Staton, CFO
(310) 267-9308
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
1/14/2019
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