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RRC100105-15 INDIAN RIVER MEMORIAL HOSPITA.L (Terminated)
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Main Details
Name
INDIAN RIVER MEMORIAL HOSPITA.L
Subdivision Name
Scully Welsh Cancer Center - HOP - AMBULATORY INFUSION
Type
Rural Referral Center
Rural
No
340B ID
RRC100105-15
Medicare Provider Number
100105
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/4/2022
Participating Start Date
4/1/2022
Participating Approval Date
2/4/2022
Last Recertification Date
8/22/2023
Termination Date
Termination Reason
4/1/2024
Outpatient facility moved within the 4 walls of the parent hospital
Contacts
Authorizing Official
Cleveland Clinic Indian River Hospital
Warren Fuller, SENIOR VP CHIEF FINANCIAL OFFICER
(772) 567-4311 Ext: 1321
Primary Contact
Cleveland Clinic
Jonathan Williams, Senior Director of Pharmacy - 340B
(216) 444-8884
Addresses
Street Address
3555 10TH CT
103
VERO BEACH, FL 32960
Billing Address
Indian River Memorial Hosp
1000 36th Street
VERO BEACH, FL 32960
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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April 2025
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