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DSH050122D DAMERON HOSPITAL ASSOCIATION (Terminated)
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Main Details
Name
DAMERON HOSPITAL ASSOCIATION
Subdivision Name
Dameron Hospital Association Core Labratory
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH050122D
Medicare Provider Number
050122
Outpatient Facility Provider Number
050122
Additional Details
Current Program Status
Terminated
Registration Date
10/8/2013
Participating Start Date
1/1/2014
Participating Approval Date
12/12/2013
Last Recertification Date
9/6/2018
Termination Date
Termination Reason
10/1/2019
Other
Contacts
Authorizing Official
Dameron Hospital
Timothy Karagounis, Operations Executive
(209) 461-7596 Ext: 2092007800
Primary Contact
Dameron Hospital
Mai Ngoc Trinh, Dameron's Linacia Pharmacy Manager, Pharmacist in Charge
(209) 242-7039
Addresses
Street Address
530 West Acacia St
Stockton, CA 95203
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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