Contract Pharmacy Details

MEDICAL CENTER PHARMACY
DSH050025 UCSD MEDICAL CENTER

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

MEDICAL CENTER PHARMACY

Pharmacy Address

340 4TH AVENUE
SUITE 1
CHULA VISTA, CA 91910

Pharmacy Comments

Contract Details

Approval Date

8/20/2012

Contract Begin Date

8/20/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

3/9/2018
Ownership change

Contacts

Covered Entity Signing Official

Lori Donaldson, CFO
(619) 543-6613

Contract Pharmacy Representative

George Awad, Pharmacy Director
(619) 997-4702

Signed By Date

8/3/2012