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RRC150012-00 ST. JOSEPHS REG MED CENTER S. BEND (Terminated)
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Main Details
Name
ST. JOSEPHS REG MED CENTER S. BEND
Subdivision Name
Type
Rural Referral Center
Rural
No
340B ID
RRC150012-00
Medicare Provider Number
150012
Additional Details
Current Program Status
Terminated
Registration Date
6/1/2023
Participating Start Date
7/1/2023
Participating Approval Date
6/7/2023
Last Recertification Date
8/18/2023
Termination Date
Termination Reason
1/1/2024
Change of covered entity type
Contacts
Authorizing Official
Loyola Medicine
Melissa M. Lukasick, CFO Illinois Region
(708) 216-5723
Primary Contact
Loyola Medicine
Zohra Saleem, Regional 340B Manager
(708) 216-3875
Addresses
Street Address
5215 HOLY CROSS PARKWAY
MISHAWAKA, IN 46545
Billing Address
Saint Joseph Regional Medical, Inc
PO Box 7007
Troy, MI 48007-7089
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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