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DSH050122L DAMERON HOSPITAL ASSOCIATION (Terminated)
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Main Details
Name
DAMERON HOSPITAL ASSOCIATION
Subdivision Name
Pacific Heart and Vascular Medical Clinic
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH050122L
Medicare Provider Number
050122
Outpatient Facility Provider Number
017223
Additional Details
Current Program Status
Terminated
Registration Date
11/9/2016
Participating Start Date
1/1/2017
Participating Approval Date
11/10/2016
Last Recertification Date
8/24/2020
Termination Date
Termination Reason
1/1/2021
Other
Contacts
Authorizing Official
Dameron Hospital
Timothy Karagounis, Operations Executive
(209) 461-7596 Ext: 2092007800
Primary Contact
Dameron Hospital
Mai Ngoc Trinh, Dameron's Linacia Pharmacy Manager, Pharmacist in Charge
(209) 242-7039
Addresses
Street Address
845 S. Fairmont Ave
Ste. 11
Lodi, CA 95240
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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April 2025
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