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DSH100025AZ SACRED HEART HOSPITAL (Terminated)
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Main Details
Name
SACRED HEART HOSPITAL
Subdivision Name
Tiger Point II / Family Medicine
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH100025AZ
Medicare Provider Number
100025
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/14/2014
Participating Start Date
4/1/2015
Participating Approval Date
2/27/2014
Last Recertification Date
8/22/2016
Termination Date
Termination Reason
10/1/2017
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
1399 Country Club Road
Gulf Breeze, FL 32563
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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3/13/15 participating 4/1/2014 thru 9/30/2014, not participating 10/1/14 thru 3/31/15 due to voluntary withdrawal, reinstated based on on-line registration submitted in Jan. 2015
03/13/2015
May 2025
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