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GARFIELD BEACH CVS, L.L.C.
DSH050168 ST JUDE MEDICAL CENTER FULLERTON
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Covered Entity Details
Entity Name
ST JUDE MEDICAL CENTER FULLERTON
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050168
Entity Address
101 E. VALENCIA MESA DR
FULLERTON, CA 92835
Medicare Provider Number
050168
Participating Start Date
7/1/2016
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
GARFIELD BEACH CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 07079
2200 N. HARBOR BLVD. (NEC)
FULLERTON, CA 92835
Pharmacy Comments
Contract Details
Approval Date
1/8/2021
Contract Begin Date
1/21/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Eugene E Gutierrez, Chief Financial Officer
(714) 992-3939
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/8/2021
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