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CREDENA HEALTH LLC
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 LLC
Pharmacy Address
7376 SW DURHAM RD
PORTLAND, OR 97224
Pharmacy Comments
Contract Details
Approval Date
7/11/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Eugene E Gutierrez, Chief Financial Officer
(714) 992-3939
Contract Pharmacy Representative
Providence St. Joseph Health
Glenn W Wachter, Outpatient Ops Strat Exec Dir, Pharmacy
(503) 962-1743
Signed By Date
7/11/2023
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