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RALEY'S PHARMACY #420
DSH050599 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050599
Entity Address
2315 STOCKTON BLVD
SACRAMENTO, CA 95817
Medicare Provider Number
050599
Participating Start Date
1/1/1999
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
RALEY'S PHARMACY #420
Pharmacy Address
8391 FOLSOM BLVD.
SACRAMENTO, CA 95826
Pharmacy Comments
Contract Details
Approval Date
10/10/2012
Contract Begin Date
10/10/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
TIMOTHY MAURICE, CHIEF FINANCIAL OFFICER
(916) 734-4055
Contract Pharmacy Representative
Raley's
Cindy Fong, Director of Pharmacy
(916) 373-6411
Signed By Date
10/15/2012
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