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DSH100025AD SACRED HEART HEALTH SYSTEM (Terminated)
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Main Details
Name
SACRED HEART HEALTH SYSTEM
Subdivision Name
SACRED HEART MEDICAL GROUP - GUTIERREZ
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH100025AD
Medicare Provider Number
100025
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
12/6/2010
Participating Start Date
1/1/2011
Participating Approval Date
12/22/2010
Last Recertification Date
11/16/2017
Termination Date
Termination Reason
7/1/2018
Site closure
Contacts
Authorizing Official
Sacred Heart Health System, Inc.
Susan Cornejo, Chief Operating Officer
(850) 416-6206
Primary Contact
Sacred Heart Health System, Inc.
Troy Russo, 340B Coordinator
(850) 416-2859
Addresses
Street Address
5149 N. NINTH AVE
#256
PENSACOLA, FL 32504
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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