Covered Entity Details

RRC050567-21 MISSION HOSPITAL REG MEDICAL CENTER (Active) - information as of 4/27/2025 1:51:11 AM

Main Details

Name

MISSION HOSPITAL REG MEDICAL CENTER

Subdivision Name

MISSION HOSPITAL - MISSION HOSPITAL REGIONAL MEDICAL CENTER - PERINATAL DIAGNOSTICS & TREATMENT CLINIC

Type

Rural Referral Center

Rural

Yes

340B ID

RRC050567-21

Medicare Provider Number

050567

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/5/2020

Participating Start Date

1/1/2021

Participating Approval Date

11/17/2020

Last Recertification Date

8/20/2024

Contacts

Authorizing Official

St. Joseph Hospital, Orange
Eileen Haubl, Chief Financial Officer
(949) 364-1400 Ext: 5408

Primary Contact

Mission Hospital
Nha-Uyen Tran, 340B Pharmacist Specialist
(949) 364-1400 Ext: 2220

Addresses

Street Address

27800 MEDICAL CENTER RD
STE 100
MISSION VIEJO, CA 92691-6407

Billing Address

St. Joseph Health Shared Services Accounts Payable
3345 Michelson Drive
100
Irvine, CA 92612

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	ZZT40567I,ZZT30567I	1912108002,1003956913,1093945412,1992752315

Shipping Addresses

Shipping Address 1

Mission Hospital
27700 Medical Center Road
Mission Viejo, CA 92691

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
RRC050567-01	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL REGIONAL MEDICAL CENTER - OUTPATIENT ENDOSCOPY	27799 MEDICAL CENTER RD	MISSION VIEJO	CA	Active
RRC050567-02	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL REGIONAL MEDICAL CENTER - OUTPATIENT BEHAVIORAL CARE CENTER	27800 MEDICAL CENTER RD	MISSION VIEJO	CA	Terminated
RRC050567-03	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - Chemical Dependency Outpatient	31872 COAST HWY	LAGUNA BEACH	CA	Terminated
RRC050567-04	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL REGIONAL MEDICAL CENTER - OUTPATIENT BEHAVIORAL HEALTH	31862 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-05	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - Cardiology	31872 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-06	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - Emergency Department	31872 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-07	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL REGIONAL MEDICAL CENTER - OUTPATIENT REHABILITAITON	26732 CROWN VALLEY PKWY	MISSION VIEJO	CA	Terminated
RRC050567-08	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - Surgical Services	31872 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-09	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL REGIONAL MEDICAL CENTER - OUTPATIENT PHYSICAL THERAPY	27882 FORBES RD	LAGUNA NIGUEL	CA	Terminated
RRC050567-10	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL REGIONAL MEDICAL CENTER - CARDIOPULMONARY REHABILITATION	26732 CROWN VALLEY PKWY	MISSION VIEJO	CA	Terminated
RRC050567-11	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - MRI	31872 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-12	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - Ultrasound	31872 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-13	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - Radiology/Mammography	31872 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-14	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - Nuclear Medicine	31872 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-15	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - Clinical Laboratory	31872 COAST HWY	LAGUNA BEACH	CA	Terminated
RRC050567-16	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - Respiratory Therapy	31872 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-17	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL REGIONAL MEDICAL CENTER - WOMEN'S WELLNESS	26732 CROWN VALLEY PKWY	MISSION VIEJO	CA	Active
RRC050567-18	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - CT Scan	31872 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-19	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL REGIONAL MEDICAL CENTER - OUTPATIENT IMAGING	27871 MEDICAL CENTER RD	MISSION VIEJO	CA	Terminated
RRC050567-20	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - Physical Therapy and Rehab Services	31872 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-21	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL REGIONAL MEDICAL CENTER - PERINATAL DIAGNOSTICS & TREATMENT CLINIC	27800 MEDICAL CENTER RD	MISSION VIEJO	CA	Active
RRC050567-22	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	PROVIDENCE MISSION HOSPITAL - Cancer Institute Radiology	27799 MEDICAL CENTER RD	MISSION VIEJO	CA	Active
RRC050567-23	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	PROVIDENCE MISSION HOSPITAL - Cancer Institute Ultrasound	27799 MEDICAL CENTER RD	MISSION VIEJO	CA	Active
RRC050567-24	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	PROVIDENCE MISSION HOSPITAL - Cancer Institute Radiation Onc	27799 MEDICAL CENTER RD	MISSION VIEJO	CA	Active
RRC050567-25	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	PROVIDENCE MISSION HOSPITAL - Cancer Institute MRI	27799 MEDICAL CENTER RD	MISSION VIEJO	CA	Active
RRC050567-26	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	PROVIDENCE MISSION HOSPITAL - Cancer Institute CT Scan	27799 MEDICAL CENTER RD	MISSION VIEJO	CA	Active
RRC050567-27	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	PROVIDENCE MISSION HOSPITAL - Cancer Institute Infusion Center	27799 MEDICAL CENTER RD	MISSION VIEJO	CA	Active
RRC050567-28	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	Providence Mission Hospital - Cancer Institute PET - Cancer Institute PET	27799 Medical Center Road	Mission Viejo	CA	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/29/2023 6:35:23 PM	8/20/2024 2:07:55 PM	8/20/2024 2:07 PM
Details	Last Recertification Date	Update	Recertification	8/31/2022 11:22:34 AM	8/29/2023 6:35:23 PM	8/29/2023 6:35 PM
Details	Last Recertification Date	Update	Recertification	8/31/2021 7:38:45 PM	8/31/2022 11:22:34 AM	8/31/2022 11:22 AM
Contacts	Primary Contact	Update	Profile Change Request	Tran, Nha-Uyen 340B Pharmacist Specialist Mission Hospital 9493641400-7912	Tran, Nha-Uyen 340B Pharmacist Specialist Mission Hospital 9493641400-2220	5/24/2022 2:58 PM
Addresses	Billing Address	Insert	Group Change Request		St. Joseph Health Shared Services Accounts Payable 3345 Michelson Drive 100 Irvine, CA 92612	2/15/2022 7:24 AM
Addresses	Shipping Address	Insert	Group Change Request		Mission Hospital 27700 Medical Center Road Mission Viejo, CA 92691	2/15/2022 7:24 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	2/15/2022 7:24 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		ZZT30567I	2/15/2022 7:24 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CA	2/15/2022 7:24 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1003956913	2/15/2022 7:24 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CA	2/15/2022 7:24 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1093945412	2/15/2022 7:24 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CA	2/15/2022 7:24 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1992752315	2/15/2022 7:24 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		CA	2/15/2022 7:24 AM
Details	Last Recertification Date	Update	Recertification		8/31/2021 7:38:45 PM	8/31/2021 7:38 PM
Contacts	Primary Contact	Update	Group Change Request	Dirig, David M Director, Pharmacy Services Mission Hospital 9493652137	Tran, Nha-Uyen 340B Pharmacist Specialist Mission Hospital 9493641400-7912	7/13/2021 7:19 AM
Details	State	Update		Approved	Active	1/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Haubl, Eileen Chief Financial Officer St. Joseph Hospital, Orange 9493641400-5408	11/17/2020 9:23 AM
Details	340B ID	Update	New Registration		RRC050567-21	11/17/2020 9:23 AM
Details	Entity Subname	Update	New Registration	MISSION HOSPITAL	MISSION HOSPITAL - MISSION HOSPITAL REGIONAL MEDICAL CENTER - PERINATAL DIAGNOSTICS & TREATMENT CLINIC	11/17/2020 9:23 AM
Dates	Participating Approval Date	Update	New Registration		11/17/2020 9:23:15 AM	11/17/2020 9:23 AM
Details	State	Update	New Registration	Pending	Approved	11/17/2020 9:23 AM
Dates	Signed By Date	Update	New Registration		11/16/2020 2:55:06 PM	11/17/2020 9:23 AM
Dates	Start Date	Update	New Registration		1/1/2021 12:00:00 AM	11/17/2020 9:23 AM
Addresses	Main Address	Insert	New Registration		27800 MEDICAL CENTER RD STE 100 MISSION VIEJO, CA 92691-6407	10/5/2020 7:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/5/2020 7:31 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		ZZT40567I	10/5/2020 7:31 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	10/5/2020 7:31 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1912108002	10/5/2020 7:31 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	10/5/2020 7:31 PM
Contacts	Authorizing Official	Insert	New Registration		Haubl, Eileen Chief Financial Officer St. Joseph Hospital, Orange 9493641400-5408	10/5/2020 7:31 PM
Contacts	Primary Contact	Insert	New Registration		Dirig, David M Director, Pharmacy Services Mission Hospital 9493652137	10/5/2020 7:31 PM
Details	Assistance Received From Date	Insert	New Registration			10/5/2020 7:31 PM
Details	Assistance Received To Date	Insert	New Registration			10/5/2020 7:31 PM
Details	Last Recertification Date	Insert	New Registration			10/5/2020 7:31 PM
Details	Grant Number	Insert	New Registration			10/5/2020 7:31 PM
Details	340B ID	Insert	New Registration			10/5/2020 7:31 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/5/2020 7:31 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/5/2020 7:31 PM
Details	Medicare Provider Number	Insert	New Registration		050567	10/5/2020 7:31 PM
Details	Entity Name	Insert	New Registration		MISSION HOSPITAL REG MEDICAL CENTER	10/5/2020 7:31 PM
Details	NOFO Number	Insert	New Registration			10/5/2020 7:31 PM
Details	Program Code	Insert	New Registration		RRC	10/5/2020 7:31 PM
Details	Entity Subname	Insert	New Registration		MISSION HOSPITAL	10/5/2020 7:31 PM
Dates	Participating Approval Date	Insert	New Registration			10/5/2020 7:31 PM
Details	State	Insert	New Registration		Pending	10/5/2020 7:31 PM
Dates	Registration Date	Insert	New Registration		10/5/2020 7:31:08 PM	10/5/2020 7:31 PM
Dates	Signed By Date	Insert	New Registration			10/5/2020 7:31 PM
Dates	Start Date	Insert	New Registration			10/5/2020 7:31 PM
Terminations	Termination Comments	Insert	New Registration			10/5/2020 7:31 PM
Terminations	Termination Date	Insert	New Registration			10/5/2020 7:31 PM
Terminations	Termination Effective Date	Insert	New Registration			10/5/2020 7:31 PM
Terminations	Termination Reason	Insert	New Registration			10/5/2020 7:31 PM