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DSH050300C ST. MARY MEDICAL CENTER (Terminated)
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Main Details
Name
ST. MARY MEDICAL CENTER
Subdivision Name
FAMILY PRACTICE AT HEALTHY BEGINNINGS APPLE VALLEY
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH050300C
Medicare Provider Number
050300
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/6/2015
Participating Start Date
1/1/2016
Participating Approval Date
11/9/2015
Last Recertification Date
8/20/2019
Termination Date
Termination Reason
7/1/2020
Change of covered entity type (non-hospital)
Contacts
Authorizing Official
St Mary Medical Center
Eugene Gutierrez, Chief Financial Officer
(760) 946-8105
Primary Contact
St Mary Medical Center
Winna Asuming, Director of Pharmacy
(760) 946-4238
Addresses
Street Address
18077 HWY 18, SU. 100
APPLE VALLEY, CA 92307-0000
Billing Address
ST MARY MEDICAL CENTER
PO BOX 696431
SAN ANTONIO, TX 78269
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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April 2025
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