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DSH050168H ST JUDE MEDICAL CENTER FULLERTON (Terminated)
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Main Details
Name
ST JUDE MEDICAL CENTER FULLERTON
Subdivision Name
ST JUDE MEDICAL CENTER SPORTS/ORTHO
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH050168H
Medicare Provider Number
050168
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/4/2016
Participating Start Date
7/1/2016
Participating Approval Date
5/11/2016
Last Recertification Date
8/22/2019
Termination Date
Termination Reason
1/1/2020
Business decision by the Covered Entity
Contacts
Authorizing Official
St. Jude Medical Center
Eugene P. Kim, Chief Medical Officer
(714) 446-5545
Primary Contact
ST JUDE MEDICAL CTR
DON MILLER, DIRECTOR OF PHARMACY
(714) 824-7235
Addresses
Street Address
2767 E IMPERIAL HWY
BREA, CA 92821
Billing Address
ST JUDE MEDICAL CENTER
PO Box 696431
San Antonio, TX 78269
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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