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CYSTIC FIBROSIS SERVICES, 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
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
7/7/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/5/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Eugene P. Kim, Chief Medical Officer
(714) 446-5545
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/7/2017
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