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DSH050168P ST JUDE MEDICAL CENTER FULLERTON (Terminated)
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Main Details
Name
ST JUDE MEDICAL CENTER FULLERTON
Subdivision Name
ST JUDE MEDICAL CENTER ULTRASOUND PLAZA
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH050168P
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
2151 N. HARBOR BLVD
Suite 1400
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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