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RRC120026-01 PALI MOMI MEDICAL CENTER (Terminated)
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Main Details
Name
PALI MOMI MEDICAL CENTER
Subdivision Name
PALI MOMI MEDICAL CENTER - Imaging Medical Pavilion - Pali Momi Outpatient Center
Type
Rural Referral Center
Rural
No
340B ID
RRC120026-01
Medicare Provider Number
120026
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/14/2020
Participating Start Date
11/9/2020
Participating Approval Date
11/9/2020
Last Recertification Date
8/16/2021
Termination Date
Termination Reason
7/1/2022
Site closure
Contacts
Authorizing Official
Hawaii Pacific Health
David E Stumbaugh, VP, Supply Chain Management and Pharmacy
(808) 522-6946
Primary Contact
Hawaii Pacific Health
Dawn Tsuha-Scarlett, Director, 340B Program and Pharmacy Regulatory Compliance
(808) 404-8382
Addresses
Street Address
98-1005 MOANALUA RD
STE 3020
AIEA, HI 96701
Billing Address
Pali Momi Medical Center
55 Merchant St, 24th Floor
Honolulu, HI 96813
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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