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POLARIS SPECIALTY RX
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
POLARIS SPECIALTY RX
Pharmacy Address
1010 E ARROW HWY
COVINA, CA 91724
Pharmacy Comments
Contract Details
Approval Date
1/11/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tammy Wallace, Chief Financial Officer Hospital System
(310) 794-8627
Contract Pharmacy Representative
Polaris Specialty
David Rombro, CEO
(816) 935-5513
Signed By Date
1/11/2024
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