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PHARMEDQUEST PHARMACY SERVICES
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
PHARMEDQUEST PHARMACY SERVICES
Pharmacy Address
DBA AVITA PHARMACY 1072
26800 CROWN VALLEY PKWY STE 185
MISSION VIEJO, CA 92691
Pharmacy Comments
Contract Details
Approval Date
5/9/2022
Contract Begin Date
5/10/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lori Donaldson, CFO
(619) 543-6613
Contract Pharmacy Representative
Avita
Chris Creamer, VP Pharmacy Operations
(214) 943-5187
Signed By Date
5/9/2022
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