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DIPLOMAT SPECIALTY PHARMACY OF SOUTHERN
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
DIPLOMAT SPECIALTY PHARMACY OF SOUTHERN
Pharmacy Address
DIPLOMAT SPECIALTY PHARMACY
1809 EXCISE AVENUE
SUITE 204-208
ONTARIO, CA 91761
Pharmacy Comments
Contract Details
Approval Date
7/6/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/1/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Lori Donaldson, CFO
(619) 543-6613
Contract Pharmacy Representative
Diplomat
Dwayne Dodd, National Sales Manager- 340B, Hospital/Health Systems
(734) 674-0050
Signed By Date
7/6/2016
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