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LONGS DRUG STORES CALIFORNIA, L.L.C.
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
LONGS DRUG STORES CALIFORNIA, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 09135
129 N EL CAMINO REAL
ENCINITAS, CA 92024
Pharmacy Comments
Contract Details
Approval Date
4/14/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lori Donaldson, CFO
(619) 543-6613
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/14/2020
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