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MI FARMACIA SAN YSIDRO
DSH050025 UCSD MEDICAL CENTER
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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
MI FARMACIA SAN YSIDRO
Pharmacy Address
4630 BORDER VILLAGE RD STE K-L
SAN YSIDRO, CA 92173-3121
Pharmacy Comments
Contract Details
Approval Date
4/26/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/16/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lori Donaldson, CFO
(619) 543-6613
Contract Pharmacy Representative
Hillcrest Pharmacy
Susan Baeza, Owner
(619) 260-1010
Signed By Date
4/26/2019
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