Covered Entity Details

DSH050678H ORANGE COAST MEMORIAL MEDICAL CENTER (Active) - information as of 5/9/2025 10:49:14 PM

Main Details

Name

ORANGE COAST MEMORIAL MEDICAL CENTER

Subdivision Name

OP SERVICES - MRI - MRI/ Imaging

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050678H

Medicare Provider Number

050678

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/17/2023

Participating Start Date

7/1/2023

Participating Approval Date

5/17/2023

Last Recertification Date

8/18/2024

Contacts

Authorizing Official

Orange Coast Memorial Medical Center
Emily Marcus Randle, COO
(714) 378-7538

Primary Contact

Orange Coast Memorial Medical Center
Stanley Hill, DIRECTOR OF PHARMACY
(714) 378-7012

Addresses

Street Address

18111 Brookhurst St
Suite 1400
Fountain Valley, CA 92708

Billing Address

Orange Coast Memorial Medical Center
9920 Talbert Ave
Fountain Valley, CA 92708

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	HSP30678G,HSP40678G	1497702575

Shipping Addresses

Shipping Address 1

Orange Coast Memorial Medical Center
9920 Talbert Ave
Fountain Valley, CA 92708

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
DSH050678A	Child	DSH	ORANGE COAST MEMORIAL MEDICAL CENTER	OP SERVICES-BREAST CENTER	9900 TALBERT AVE	FOUNTAIN VALLEY	CA	Terminated
DSH050678B	Child	DSH	ORANGE COAST MEMORIAL MEDICAL CENTER	OP SERVICES-CARDIOLOGY	18111 BROOKHURST ST 2200	FOUNTAIN VALLEY	CA	Active
DSH050678C	Child	DSH	ORANGE COAST MEMORIAL MEDICAL CENTER	OP SERVICES-INFUSION CENTER	18111 BROOKHURST ST 4300B	FOUNTAIN VALLEY	CA	Active
DSH050678D	Child	DSH	ORANGE COAST MEMORIAL MEDICAL CENTER	OP SERVICES - NUCLEAR MEDICINE - Nuclear Medicine	18111 Brookhurst St.	Fountain Valley	CA	Active
DSH050678E	Child	DSH	ORANGE COAST MEMORIAL MEDICAL CENTER	OP SERVICES - PULMONARY LAB - Pulmonary Function Service	18111 Brookhurst St.	Fountain Valley	CA	Active
DSH050678F	Child	DSH	ORANGE COAST MEMORIAL MEDICAL CENTER	OP SERVICES - PET SCAN/ Imaging	18111 BROOKHURST ST	FOUNTAIN VALLEY	CA	Active
DSH050678G	Child	DSH	ORANGE COAST MEMORIAL MEDICAL CENTER	OP SERVICES - CT SCAN - MIC - CT Scan/ Imaging	18111 Brookhurst St	Fountain Valley	CA	Active
DSH050678H	Child	DSH	ORANGE COAST MEMORIAL MEDICAL CENTER	OP SERVICES - MRI - MRI/ Imaging	18111 Brookhurst St	Fountain Valley	CA	Active
DSH050678J	Child	DSH	ORANGE COAST MEMORIAL MEDICAL CENTER	MEMORIALCARE ORANGE COAST MEDICAL C - Ambulatory Infusion Care South	24411 HEALTH CENTER DR	LAGUNA HILLS	CA	Active
DSH050678K	Child	DSH	ORANGE COAST MEMORIAL MEDICAL CENTER	MEMORIALCARE ORANGE COAST MEDICAL C - OCM Radiation Oncology	18111 BROOKHURST ST	FOUNTAIN VALLEY	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/25/2023 11:07:42 AM	8/18/2024 10:39:01 PM	8/18/2024 10:39 PM
Details	Last Recertification Date	Update	Recertification		8/25/2023 11:07:42 AM	8/25/2023 11:07 AM
Details	State	Update		Approved	Active	7/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Randle, Emily Marcus COO Orange Coast Memorial Medical Center 7143787538	5/17/2023 8:50 AM
Details	340B ID	Update	New Registration		DSH050678H	5/17/2023 8:50 AM
Details	Entity Name	Update	New Registration	MEMORIALCARE ORANGE COAST MED CTR	ORANGE COAST MEMORIAL MEDICAL CENTER	5/17/2023 8:50 AM
Details	Entity Subname	Update	New Registration	OP SERVICES - MRI	OP SERVICES - MRI - MRI/ Imaging	5/17/2023 8:50 AM
Dates	Participating Approval Date	Update	New Registration		5/17/2023 8:50:08 AM	5/17/2023 8:50 AM
Details	State	Update	New Registration	Pending	Approved	5/17/2023 8:50 AM
Dates	Signed By Date	Update	New Registration		4/17/2023 9:53:41 PM	5/17/2023 8:50 AM
Dates	Start Date	Update	New Registration		7/1/2023 12:00:00 AM	5/17/2023 8:50 AM
Addresses	Main Address	Insert	New Registration		18111 Brookhurst St Suite 1400 Fountain Valley, CA 92708	4/17/2023 8:10 PM
Addresses	Billing Address	Insert	New Registration		Orange Coast Memorial Medical Center 9920 Talbert Ave Fountain Valley, CA 92708	4/17/2023 8:10 PM
Addresses	Shipping Address	Insert	New Registration		Orange Coast Memorial Medical Center 9920 Talbert Ave Fountain Valley, CA 92708	4/17/2023 8:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/17/2023 8:10 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		HSP30678G	4/17/2023 8:10 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/17/2023 8:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/17/2023 8:10 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		HSP40678G	4/17/2023 8:10 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/17/2023 8:10 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1497702575	4/17/2023 8:10 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/17/2023 8:10 PM
Contacts	Primary Contact	Insert	New Registration		Hill, Stanley DIRECTOR OF PHARMACY Orange Coast Memorial Medical Center 7143787012	4/17/2023 8:10 PM
Contacts	Authorizing Official	Insert	New Registration		Randle, Emily Marcus COO Orange Coast Memorial Medical Center 7143787538	4/17/2023 8:10 PM
Details	Assistance Received From Date	Insert	New Registration			4/17/2023 8:10 PM
Details	Assistance Received To Date	Insert	New Registration			4/17/2023 8:10 PM
Details	Last Recertification Date	Insert	New Registration			4/17/2023 8:10 PM
Details	Grant Number	Insert	New Registration			4/17/2023 8:10 PM
Details	340B ID	Insert	New Registration			4/17/2023 8:10 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/17/2023 8:10 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/17/2023 8:10 PM
Details	Medicare Provider Number	Insert	New Registration		050678	4/17/2023 8:10 PM
Details	Entity Name	Insert	New Registration		MEMORIALCARE ORANGE COAST MED CTR	4/17/2023 8:10 PM
Details	NOFO Number	Insert	New Registration			4/17/2023 8:10 PM
Details	Program Code	Insert	New Registration		DSH	4/17/2023 8:10 PM
Details	Entity Subname	Insert	New Registration		OP SERVICES - MRI	4/17/2023 8:10 PM
Dates	Participating Approval Date	Insert	New Registration			4/17/2023 8:10 PM
Details	State	Insert	New Registration		Pending	4/17/2023 8:10 PM
Dates	Registration Date	Insert	New Registration		4/17/2023 8:10:51 PM	4/17/2023 8:10 PM
Dates	Signed By Date	Insert	New Registration			4/17/2023 8:10 PM
Dates	Start Date	Insert	New Registration			4/17/2023 8:10 PM
Terminations	Termination Comments	Insert	New Registration			4/17/2023 8:10 PM
Terminations	Termination Date	Insert	New Registration			4/17/2023 8:10 PM
Terminations	Termination Effective Date	Insert	New Registration			4/17/2023 8:10 PM
Terminations	Termination Reason	Insert	New Registration			4/17/2023 8:10 PM