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BRIOVARX OF MAINE INC
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
BRIOVARX OF MAINE INC
Pharmacy Address
DBA BRIOVARX
53 DARLING AVE
SOUTH PORTLAND, ME 04106
Pharmacy Comments
Contract Details
Approval Date
7/18/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/14/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
TIMOTHY MAURICE, CHIEF FINANCIAL OFFICER
(916) 734-4055
Contract Pharmacy Representative
Optum RX
Joseph Iovino, VP
(412) 445-4495
Signed By Date
7/18/2017
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