Contract Pharmacy Details

LONGS DRUG STORES CALIFORNIA, L.L.C.
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

LONGS DRUG STORES CALIFORNIA, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 09538
1792 GARNET AVE
SAN DIEGO, CA 92109

Pharmacy Comments

Contract Details

Approval Date

1/14/2015

Contract Begin Date

4/1/2015

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/26/2017
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Lori Donaldson, CFO
(619) 543-6613

Contract Pharmacy Representative

CVS Caremark
JACKLYN PARFITT, MANAGER, PAYER RELATIONS
(401) 770-6467

Signed By Date

1/14/2015

340B Drug Pricing Program Database