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CAREMARK TENNESSEE SPECIALTY PHARMACY, L
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
CAREMARK TENNESSEE SPECIALTY PHARMACY, L
Pharmacy Address
DBA CVS/SPECIALTY OR CARELONRX SPECIALTY
8370 WOLF LAKE DR
STE 107
BARTLETT, TN 38133
Pharmacy Comments
Contract Details
Approval Date
4/8/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/30/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lori Donaldson, CFO
(619) 543-6613
Contract Pharmacy Representative
CVS HEALTH
Joan O'Rourke, VP Specialty Program Management
(847) 559-5282
Signed By Date
4/8/2016
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