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DSH050168L ST JUDE MEDICAL CENTER FULLERTON (Active)
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Main Details
Name
ST JUDE MEDICAL CENTER FULLERTON
Subdivision Name
ST JUDE MEDICAL CENTER DIAGNOSTIC RADIOLOGY PLAZA
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH050168L
Medicare Provider Number
050168
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
1/24/2022
Participating Start Date
4/1/2022
Participating Approval Date
1/26/2022
Last Recertification Date
8/21/2024
Contacts
Authorizing Official
St. Jude Medical Center
Eugene E Gutierrez, Chief Financial Officer
(714) 992-3939
Primary Contact
St. Jude Medical Center
Ray Juergens, Pharmacy Director
(714) 992-3000 Ext: 4050
Addresses
Street Address
2141 N. HARBOR BLVD
Suite 16000
FULLERTON, CA 92835
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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Participating Start Date 7/1/2016, Termination Date 1/1/2020, Reinstatement 4/1/2022
01/25/2022
April 2025
April 2025
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