Contract Pharmacy Details

WALGREEN CO.
DSH050348 UCI MEDICAL CENTER

Covered Entity Details

Entity Name

UCI MEDICAL CENTER

Subdivision Name

UNIVERSITY OF CALIFORNIA, IRVINE

Type

Disproportionate Share Hospital

340B ID

DSH050348

Entity Address

101 THE CITY DR. S RT32
ORANGE, CA 92868

Medicare Provider Number

050348

Participating Start Date

1/1/1998

Last Recertification Date

8/29/2024

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS # 07303
100 W ONTARIO AVE
CORONA, CA 92882-5215

Pharmacy Comments

Contract Details

Approval Date

11/7/2012

Contract Begin Date

11/7/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2016
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Terry Belmont, CEO
(714) 456-6240

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

11/7/2012

340B Drug Pricing Program Database