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ACARIAHEALTH PHARMACY #13, INC
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
ACARIAHEALTH PHARMACY #13, INC
Pharmacy Address
3302 GARFIELD AVE.
COMMERCE, CA 90040-3102
Pharmacy Comments
Contract Details
Approval Date
7/9/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Paul Staton, CFO
(310) 267-9308
Contract Pharmacy Representative
Acaria Health
Philip Gofman, Regional VP
(917) 312-5263
Signed By Date
7/9/2020
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