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CORAM HEALTHCARE CORP OF SOUTHERN CALIFO
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
CORAM HEALTHCARE CORP OF SOUTHERN CALIFO
Pharmacy Address
DBA CORAM CVS/SPECIALTY INFUSION SERVICE
3002 DOW AVENUE
STE 104
TUSTIN, CA 92780
Pharmacy Comments
Contract Details
Approval Date
10/12/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2020
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
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/12/2017
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