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DSH050300E ST. MARY MEDICAL CENTER (Terminated)
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Main Details
Name
ST. MARY MEDICAL CENTER
Subdivision Name
FAMILY PRACTICE AT HESPERIA COMMUNITY HEALTH CENTER - FAMILY CLINIC
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH050300E
Medicare Provider Number
050300
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
7/13/2018
Participating Start Date
10/1/2018
Participating Approval Date
7/31/2018
Last Recertification Date
8/20/2019
Termination Date
Termination Reason
7/1/2020
Change of covered entity type (non-hospital)
Contacts
Authorizing Official
St Mary Medical Center
Eugene Gutierrez, Chief Financial Officer
(760) 946-8105
Primary Contact
St Mary Medical Center
Winna Asuming, Director of Pharmacy
(760) 946-4238
Addresses
Street Address
17071 MAIN STREET
HESPERIA, CA 92345
Billing Address
ST MARY MEDICAL CENTER
PO BOX 696431
SAN ANTONIO, TX 78269
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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