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MISSION PLAZA 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
MISSION PLAZA PHARMACY
Pharmacy Address
26800 CROWN VALLEY PKWY STE 185
MISSION VIEJO, CA 92691-7304
Pharmacy Comments
Contract Details
Approval Date
7/24/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/10/2022
Ownership change
Contacts
Covered Entity Signing Official
Lori Donaldson, CFO
(619) 543-6613
Contract Pharmacy Representative
Vimal Bhanvadia, Managing Partner
(949) 364-9009
Signed By Date
7/24/2014
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