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CAH501323-07 JEFFERSON HEALTHCARE (Active)
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Main Details
Name
JEFFERSON HEALTHCARE
Subdivision Name
JEFFERSON Healthcare Port Ludlow Clinic
Type
Critical Access Hospital
Rural
Yes
340B ID
CAH501323-07
Medicare Provider Number
501323
Outpatient Facility Provider Number
508572
Additional Details
Current Program Status
Active
Registration Date
10/9/2018
Participating Start Date
1/1/2019
Participating Approval Date
11/23/2018
Last Recertification Date
8/16/2024
Contacts
Authorizing Official
Jefferson Healthcare
Jacob Bujacich Davidson, Chief Operating Officer
(360) 385-2200 Ext: 2039
Primary Contact
Jefferson Healthcare
Andrew John Nelson, Director of Pharmacy
(360) 385-2200 Ext: 2345
Addresses
Street Address
89 BREAKER LN
PORT LUDLOW, WA 98365-9766
Billing Address
Jefferson Healthcare Pharmacy
834 Sheridan St
Port Townsend, WA 98368
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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