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RALPHS GROCERY CO
DSH050025 UCSD MEDICAL CENTER
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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
RALPHS GROCERY CO
Pharmacy Address
DBA RALPHS #108
8657 VILLA LA JOLLA DR
#108
LA JOLLA, CA 92037
Pharmacy Comments
Contract Details
Approval Date
12/5/2012
Contract Begin Date
12/5/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lori Donaldson, CFO
(619) 543-6613
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
9/30/2012
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