Covered Entity Details

DSH050168E ST JUDE MEDICAL CENTER FULLERTON (Active) - information as of 4/28/2025 11:27:50 PM

Main Details

Name

ST JUDE MEDICAL CENTER FULLERTON

Subdivision Name

ST JUDE MEDICAL CENTER KNOTT FAMILY ENDOSCOPY CENTER

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050168E

Medicare Provider Number

050168

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/4/2016

Participating Start Date

7/1/2016

Participating Approval Date

5/11/2016

Last Recertification Date

8/21/2024

Contacts

Authorizing Official

St. Jude Medical Center
Eugene E Gutierrez, Chief Financial Officer
(714) 992-3939

Primary Contact

St. Jude Medical Center
Ray Juergens, Pharmacy Director
(714) 992-3000 Ext: 4050

Addresses

Street Address

1839 SUNNYCREST DR
FULLERTON, CA 92835

Billing Address

ST JUDE MEDICAL CENTER
PO Box 696431
San Antonio, TX 78269

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
CA	ZZT40168F,ZZT30168F,HSC30168F	1194926279,1891904942

Shipping Addresses

Shipping Address 1

ST JUDE MEDICAL CENTER
101 E VALENCIA MESA DR
FULLERTON, CA 92835

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH050168A	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	ST JUDE MEDICAL CENTER CT SCAN PLAZA	2151 N. HARBOR BLVD	FULLERTON	CA	Terminated
DSH050168B	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	ST JUDE MEDICAL CENTER CT SCAN YORBA LINDA	4300 ROSE DR	YORBA LINDA	CA	Terminated
DSH050168C	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	ST JUDE MEDICAL CENTER MRI PLAZA	2151 N. HARBOR BLVD	FULLERTON	CA	Terminated
DSH050168D	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	ST JUDE MEDICAL CENTER MRI YORBA LINDA	4300 ROSE DR	YORBA LINDA	CA	Terminated
DSH050168E	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	ST JUDE MEDICAL CENTER KNOTT FAMILY ENDOSCOPY CENTER	1839 SUNNYCREST DR	FULLERTON	CA	Active
DSH050168F	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	ST JUDE MEDICAL CENTER PRE OP SURGERY	2141 N. HARBOR BLVD	FULLERTON	CA	Active
DSH050168G	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	ST JUDE MEDICAL CENTER PLAZA SURGERY CENTER	2141 N. HARBOR BLVD	FULLERTON	CA	Active
DSH050168H	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	ST JUDE MEDICAL CENTER SPORTS/ORTHO	2767 E IMPERIAL HWY	BREA	CA	Terminated
DSH050168J	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	ST JUDE MEDICAL CENTER COGNITIVE RECOVERY CENTER	2767 E IMPERIAL HWY	BREA	CA	Terminated
DSH050168K	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	ST JUDE MEDICAL CENTER COMPREHENSIVE CARDIAC REHAB	100 E. VALENCIA MESA DR	FULLERTON	CA	Active
DSH050168L	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	ST JUDE MEDICAL CENTER DIAGNOSTIC RADIOLOGY PLAZA	2141 N. HARBOR BLVD	FULLERTON	CA	Active
DSH050168M	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	ST JUDE MEDICAL CENTER DIAGNOSTIC RADIOLOGY YORBA LINDA	4300 ROSE DR	YORBA LINDA	CA	Terminated
DSH050168N	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	ST JUDE MEDICAL CENTER MAMMOGRAPHY YORBA LINDA	4300 ROSE DR	YORBA LINDA	CA	Terminated
DSH050168P	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	ST JUDE MEDICAL CENTER ULTRASOUND PLAZA	2151 N. HARBOR BLVD	FULLERTON	CA	Terminated
DSH050168Q	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	ST JUDE MEDICAL CENTER ULTRASOUND YORBA LINDA	4300 ROSE DR	YORBA LINDA	CA	Terminated
DSH050168R	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	ST JUDE MEDICAL CENTER PET SCAN PLAZA	2141 N. HARBOR BLVD	FULLERTON	CA	Active
DSH050168S	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	ST JUDE MEDICAL CENTER NUCLEAR MEDICINE PLAZA	2141 N. HARBOR BLVD	FULLERTON	CA	Active
DSH050168T	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	ST JUDE MEDICAL CENTER RADIATION ONCOLOGY	2151 N. HARBOR BLVD	FULLERTON	CA	Active
DSH050168U	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	ST JUDE MEDICAL CENTER SPECIALTY SERVICES CHRONIC PAIN MGMT	2767 E Imperial Hwy	Brea	CA	Terminated
DSH050168V	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	INFUSION CENTER (CANCER CTR) - INFUSION CENTER (CANCER CTR)	2151 N. Harbor Blvd	FULLERTON	CA	Active
DSH050168W	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	St Jude Medical Center MRI Plaza - St Jude Medical Center MRI Plaza	2151 N HARBOR BLVD	Fullerton	CA	Active
DSH050168X	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	St Jude Medical Center Ultrasound Plaza - St Jude Medical Center Ultrasound Plaza	2151 N HARBOR BLVD	Fullerton	CA	Active
DSH050168Y	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	St Jude Medical Center CT Scan Plaza - St Jude Medical Center CT Scan Plaza	2151 N HARBOR BLVD	Fullerton	CA	Active
DSH050168Z	Child	DSH	ST JUDE MEDICAL CENTER FULLERTON	St Jude Medical Center Fullerton - Pharmacotherapy	2151 N HARBOR BLVD	Fullerton	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Recertification	MILLER, DON DIRECTOR OF PHARMACY ST JUDE MEDICAL CTR 7148247235	Juergens, Ray Pharmacy Director St. Jude Medical Center 7149923000-4050	8/21/2024 2:19 PM
Details	Last Recertification Date	Update	Recertification	8/29/2023 4:32:05 PM	8/21/2024 2:19:56 PM	8/21/2024 2:19 PM
Details	Last Recertification Date	Update	Recertification	8/31/2022 2:30:51 PM	8/29/2023 4:32:05 PM	8/29/2023 4:32 PM
Details	Last Recertification Date	Update	Recertification	8/27/2021 7:05:18 PM	8/31/2022 2:30:51 PM	8/31/2022 2:30 PM
Details	Last Recertification Date	Update	Recertification	9/1/2020 12:48:57 PM	8/27/2021 7:05:18 PM	8/27/2021 7:05 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/1/2020 12:48 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/1/2020 12:48 PM
Details	Last Recertification Date	Update	Recertification	8/22/2019 8:18:44 PM	9/1/2020 12:48:57 PM	9/1/2020 12:48 PM
Contacts	Authorizing Official	Update	Change Request	Kim, Eugene P. Chief Medical Officer St. Jude Medical Center 7144465545	Gutierrez, Eugene E Chief Financial Officer St. Jude Medical Center 7149923939	8/5/2020 8:28 AM
Dates	Last Date That 340B Drugs Purchased	Update	OPA Cancel Termination Request	1/14/2020 12:00:00 AM		1/22/2020 9:31 AM
Details	State	Update	OPA Cancel Termination Request	To Be Terminated	Active	1/22/2020 9:31 AM
Terminations	Termination Date	Update	OPA Cancel Termination Request	4/1/2020 12:00:00 AM		1/22/2020 9:31 AM
Terminations	Termination Effective Date	Update	OPA Cancel Termination Request	1/14/2020 12:00:00 AM		1/22/2020 9:31 AM
Terminations	Termination Reason	Update	OPA Cancel Termination Request	Business decision by the Covered Entity		1/22/2020 9:31 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		1/14/2020 12:00:00 AM	1/21/2020 1:26 PM
Details	State	Update	Termination Request	Active	To Be Terminated	1/21/2020 1:26 PM
Terminations	Termination Date	Update	Termination Request		4/1/2020 12:00:00 AM	1/21/2020 1:26 PM
Terminations	Termination Effective Date	Update	Termination Request		1/14/2020 12:00:00 AM	1/21/2020 1:26 PM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	1/21/2020 1:26 PM
Contacts	Primary Contact	Update	Change Request	Yu, Belinda Regional Controller OC/HD Providence St Joseph Health System 9493814670	MILLER, DON DIRECTOR OF PHARMACY ST JUDE MEDICAL CTR 7148247235	10/28/2019 2:22 PM
Addresses	Billing Address	Update	Recertification	ST JUDE MEDICAL CENTER 101 E VALENCIA MESA DR FULLERTON, CA 92835	ST JUDE MEDICAL CENTER PO Box 696431 San Antonio, TX 78269	8/22/2019 8:18 PM
Details	Last Recertification Date	Update	Recertification	8/24/2018 4:27:33 PM	8/22/2019 8:18:44 PM	8/22/2019 8:18 PM
Addresses	Main Address	Update	Change Request	1847 SUNNYCREST DR FULLERTON, CA 92835	1839 SUNNYCREST DR FULLERTON, CA 92835	2/13/2019 3:25 PM
Details	Last Recertification Date	Update	Recertification	11/14/2017 12:29:44 PM	8/24/2018 4:27:33 PM	8/24/2018 4:27 PM
Contacts	Primary Contact	Update	Change Request	Lauper, Barbara Cook Finance Manager St Jude Medical Center 7144467233	Yu, Belinda Regional Controller OC/HD Providence St Joseph Health System 9493814670	6/13/2018 2:02 PM
Contacts	Primary Contact	Insert	Recertification		Lauper, Barbara Cook Finance Manager St Jude Medical Center 7144467233	11/14/2017 12:29 PM
Details	Last Recertification Date	Update	Recertification	8/23/2016 12:00:00 AM	11/14/2017 12:29:44 PM	11/14/2017 12:29 PM
Contacts	Authorizing Official	Update		Kim, Eugene P. Chief Medical Officer 7144465545	Kim, Eugene P. Chief Medical Officer St. Jude Medical Center 7144465545	10/10/2017 2:54 PM
Contacts	Signed By	Insert			Salvador, Ed Chief Financial Officer 7149923939	7/28/2017 10:24 AM
Contacts	Authorizing Official	Update		Salvador, Ed Chief Financial Officer 7149923939	Kim, Eugene P. Chief Medical Officer 7144465545	7/28/2017 10:24 AM
Addresses	Main Address	Insert			1847 SUNNYCREST DR FULLERTON, CA 92835	7/28/2017 10:23 AM
Addresses	Billing Address	Insert			ST JUDE MEDICAL CENTER 101 E VALENCIA MESA DR FULLERTON, CA 92835	7/28/2017 10:23 AM
Addresses	Shipping Address	Insert			ST JUDE MEDICAL CENTER 101 E VALENCIA MESA DR FULLERTON, CA 92835	7/28/2017 10:23 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/28/2017 10:23 AM
Medicaid Billing	Medicaid: Number	Insert			ZZT30168F	7/28/2017 10:23 AM
Medicaid Billing	Medicaid: State	Insert			CA	7/28/2017 10:23 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/28/2017 10:23 AM
Medicaid Billing	Medicaid: Number	Insert			HSC30168F	7/28/2017 10:23 AM
Medicaid Billing	Medicaid: State	Insert			CA	7/28/2017 10:23 AM
Medicaid Billing	NPI: Number	Insert			1891904942	7/28/2017 10:23 AM
Contacts	Authorizing Official	Insert			Salvador, Ed Chief Financial Officer 7149923939	4/17/2017 5:59 PM
Details	Last Recertification Date	Update			8/23/2016 12:00:00 AM	8/23/2016 5:02 PM
Dates	Participating Approval Date	Update			5/11/2016 12:00:00 AM	5/11/2016 2:45 PM
Details	State	Update		Pending	Active	5/11/2016 2:45 PM
Dates	Start Date	Update			7/1/2016 12:00:00 AM	5/11/2016 2:45 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_58900	DSH050168E	5/11/2016 10:01 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_58900	4/4/2016 3:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/4/2016 3:41 PM
Medicaid Billing	Medicaid: Number	Insert			ZZT40168F	4/4/2016 3:41 PM
Medicaid Billing	Medicaid: State	Insert			CA	4/4/2016 3:41 PM
Medicaid Billing	NPI: Number	Insert			1194926279	4/4/2016 3:41 PM
Details	Last Recertification Date	Insert				4/4/2016 3:41 PM
Details	Grant Number	Insert				4/4/2016 3:41 PM
Details	340B ID	Insert				4/4/2016 3:41 PM
Details	Is Authorizing Official EHB Data	Insert				4/4/2016 3:41 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/4/2016 3:41 PM
Details	Medicare Provider Number	Insert			050168	4/4/2016 3:41 PM
Details	Entity Name	Insert			ST JUDE MEDICAL CENTER FULLERTON	4/4/2016 3:41 PM
Details	Program Code	Insert			DSH	4/4/2016 3:41 PM
Details	Entity Subname	Insert			ST JUDE MEDICAL CENTER KNOTT FAMILY ENDOSCOPY CENTER	4/4/2016 3:41 PM
Dates	Participating Approval Date	Insert				4/4/2016 3:41 PM
Details	State	Insert			Pending	4/4/2016 3:41 PM
Dates	Registration Date	Insert			4/4/2016 12:00:00 AM	4/4/2016 3:41 PM
Dates	Signed By Date	Insert			4/4/2016 12:00:00 AM	4/4/2016 3:41 PM
Dates	Start Date	Insert				4/4/2016 3:41 PM
Terminations	Termination Comments	Insert				4/4/2016 3:41 PM
Terminations	Termination Date	Insert				4/4/2016 3:41 PM
Terminations	Termination Effective Date	Insert				4/4/2016 3:41 PM
Terminations	Termination Reason	Insert				4/4/2016 3:41 PM