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DSH050278 PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE HOLY CROSS MEDICAL CENTER (Active)
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Main Details
Name
PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE HOLY CROSS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH050278
Medicare Provider Number
050278
Additional Details
Current Program Status
Active
Registration Date
4/22/2008
Participating Start Date
7/1/2005
Participating Approval Date
4/22/2008
Last Recertification Date
8/15/2024
Contacts
Authorizing Official
Providence
Jason Kell, Chief Financial Officer
(415) 505-5231
Primary Contact
Providence Holy Cross Medical Center
Michelle Godinez Vargas, Director Pharmacy Services
(818) 496-4594
Addresses
Street Address
15031 RINALDI STREET
MISSION HILLS, CA 91345
Billing Address
Providence Holy Cross Medical Center
PO Box 696430
San Antonio, TX 78269
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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7/31/09 UPDATED ENTITY NAME (WAS PROVIDENCE HOLY CROSS MEDICAL CENTER) AND AUTHORIZING OFFICIAL
07/31/2009
April 2025
April 2025
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