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PED053305-03 LUCILE PACKARD CHILDREN'S HOSPITAL (Terminated)
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Main Details
Name
LUCILE PACKARD CHILDREN'S HOSPITAL
Subdivision Name
CASTRO COMMONS
Type
Children's Hospital
Rural
No
340B ID
PED053305-03
Medicare Provider Number
053305
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/17/2010
Participating Start Date
1/19/2010
Participating Approval Date
1/19/2010
Last Recertification Date
8/24/2016
Termination Date
Termination Reason
10/1/2016
Site closure
Contacts
Authorizing Official
Lucile Packard Children's Hospital
Rick Stephen Majzun, COO
(650) 723-0418
Primary Contact
Fred Nishioka, Director of Pharmacy
(650) 497-8781
Addresses
Street Address
1174 CASTRO ST.
STE. 250
MOUNTAIN VIEW, CA 94040
Billing Address
LUCILE PACKARD CHILDREN'S HOSPITAL-ACCOUNTS PAYABLE
725 WELCH ROAD MC5553
PALO ALTO, CA 94304
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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