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CREDENA HEALTH PHARMACY FULLERTON
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
CREDENA HEALTH PHARMACY FULLERTON
Pharmacy Address
1950 SUNNY CREST DR STE 1200
FULLERTON, CA 92835
Pharmacy Comments
Contract Details
Approval Date
10/24/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Eugene E Gutierrez, Chief Financial Officer
(714) 992-3939
Contract Pharmacy Representative
Providence
Tammy Pierce, Director of Pharmacy
(503) 962-1700
Signed By Date
10/24/2022
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