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DSH050078 PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER SAN PEDRO (Active)
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Main Details
Name
PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER SAN PEDRO
Subdivision Name
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH050078
Medicare Provider Number
050078
Additional Details
Current Program Status
Active
Registration Date
4/11/2008
Participating Start Date
7/1/2005
Participating Approval Date
4/11/2008
Last Recertification Date
8/23/2024
Contacts
Authorizing Official
Providence Health & Services Little Company of Mary Medical Centers San Pedro and Torrance
John Fleming Goeders, Chief Financial Officer
(310) 829-8411
Primary Contact
Providence Little Company of Mary Medical Center
Muno Bholat, Director of Pharmacy
(310) 303-5722
Addresses
Street Address
1300 W 7TH STREET
SAN PEDRO, CA 90732
Billing Address
Providence Hlth Svcs
PO Box 389673
Seattle, WA 98138-9673
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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6/19/2009- UPDATED ENTITY NAME (WAS LITTLE COMPANY OF MARY - SAN PEDRO HOSPITAL) AND AUTHORIZING OFFICIAL (WAS ARNOLD SCHAFFER, VP/CEO)
06/19/2009
April 2025
April 2025
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