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MEDICAL CENTER PHARMACY
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
MEDICAL CENTER PHARMACY
Pharmacy Address
PARK MEDICAL PHARMACY
480 4TH AVE STE 100
CHULA VISTA, CA 91910
Pharmacy Comments
Contract Details
Approval Date
7/17/2013
Contract Begin Date
10/1/2013
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
Community Medical Center Pharmacy
Michelle Darnelle, Operations / Business Development Manager
(619) 206-0117
Signed By Date
7/17/2013
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