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DSH050168W ST JUDE MEDICAL CENTER FULLERTON (Active)
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Main Details
Name
ST JUDE MEDICAL CENTER FULLERTON
Subdivision Name
St Jude Medical Center MRI Plaza - St Jude Medical Center MRI Plaza
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH050168W
Medicare Provider Number
050168
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
1/12/2022
Participating Start Date
4/1/2022
Participating Approval Date
1/21/2022
Last Recertification Date
8/21/2024
Contacts
Authorizing Official
St. Jude Medical Center
Eugene E Gutierrez, Chief Financial Officer
(714) 992-3939
Primary Contact
St. Jude Medical Center
Ray Juergens, Pharmacy Director
(714) 992-3000 Ext: 4050
Addresses
Street Address
2151 N HARBOR BLVD
SUITE 1400
Fullerton, CA 92835
Billing Address
ST JUDE MEDICAL CENTER
PO BOX 696431
SAN ANTONIO, TX 78269
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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