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DSH100025CC SACRED HEART HEALTH SYSTEM (Terminated)
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Main Details
Name
SACRED HEART HEALTH SYSTEM
Subdivision Name
SACRED HEART MEDICAL GROUP -CRESTVIEW Meternal Fetal Med
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH100025CC
Medicare Provider Number
100025
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/14/2016
Participating Start Date
7/1/2016
Participating Approval Date
5/27/2016
Last Recertification Date
9/6/2019
Termination Date
Termination Reason
10/1/2020
Site closure
Contacts
Authorizing Official
Sacred Heart Health System, Inc.
Susan Cornejo, Chief Operating Officer
(850) 416-6206
Primary Contact
Sacred Heart Health System, Inc.
Troy Russo, 340B Coordinator
(850) 416-2859
Addresses
Street Address
550 W. Redstone Ave. Suite 450
Suite 450
Crestview, FL 32536
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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