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DSH050136A PETALUMA VALLEY HOSPITAL (Terminated)
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Main Details
Name
PETALUMA VALLEY HOSPITAL
Subdivision Name
PVH - Lynch Creek Radiology
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH050136A
Medicare Provider Number
050136
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/12/2015
Participating Start Date
4/1/2015
Participating Approval Date
3/11/2015
Last Recertification Date
8/20/2019
Termination Date
Termination Reason
10/1/2020
Hospital Outpatient facility no longer eligible
Contacts
Authorizing Official
Providence St. Joseph Health
Patti Pilgrim, Regional CFO
(707) 525-5323
Primary Contact
Providence St. Joseph Health
Caroline Chellamy, Regional Director, 340B Operations
(424) 259-3784
Addresses
Street Address
110 Lynch Creek Way
Suite B
Petaluma, CA 94954
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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