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DSH050122H DAMERON HOSPITAL ASSOCIATION (Terminated)
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Main Details
Name
DAMERON HOSPITAL ASSOCIATION
Subdivision Name
Employee Medical Clinic Suite #19
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH050122H
Medicare Provider Number
050122
Outpatient Facility Provider Number
050122
Additional Details
Current Program Status
Terminated
Registration Date
4/11/2014
Participating Start Date
7/1/2014
Participating Approval Date
6/11/2014
Last Recertification Date
12/1/2017
Termination Date
Termination Reason
10/1/2018
Site closure
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 W. Acacia St
Suite # 1
Stocton, CA, CA 95203
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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