Covered Entity Details

DSH050696Q Keck Hospital of USC (Active) - information as of 6/19/2025 11:52:38 PM

Main Details

Name

Keck Hospital of USC

Subdivision Name

Keck Pasadena Clinic - Ophthalmology

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH050696Q

Medicare Provider Number

050696

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/20/2012

Participating Start Date

7/1/2012

Participating Approval Date

6/27/2012

Last Recertification Date

8/22/2024

Contacts

Authorizing Official

Keck Medicine of USC
Rod Hanners, Chief Operating Officer
(323) 442-8677

Primary Contact

Keck Medicine of USC
Krist Azizian, Chief Pharmacy Officer
(323) 865-3588

Addresses

Street Address

625 South Fair Oaks Avenue
Room 4100
400
Pasadena, CA 91105

Billing Address

Keck Hospital of USC
1500 San Pablo St.
Los Angeles, CA 90033

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
CA	HSP40696G	1952546616,1013514199

Shipping Addresses

Shipping Address 1

Keck Hospital of USC Pharmacy
1500 San Pablo Street
Los Angeles, CA 90033

Shipping Address 2

Keck Hospital of USC-Arcadia Treatment Center
125 W. Huntington Drive Building A
A300
Room 309
Arcadia, CA 91007

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH050696A	Child	DSH	Keck Hospital of USC	Ortho	1520 SAN PABLO STREET	LOS ANGELES	CA	Active
DSH050696AA	Child	DSH	Keck Hospital of USC	Treatment Center (Infusion)	1516 San Pablo Street	Los Angeles	CA	Active
DSH050696AB	Child	DSH	Keck Hospital of USC	Keck Medicine of USC - USC Roski Eye Institute - Ophthalmology	1450 San Pablo St.	Los Angeles	CA	Active
DSH050696AC	Child	DSH	Keck Hospital of USC	OP Surgery Center - HC3 - Ambulatory Surgery	1516 San Pablo St.	Los Angeles	CA	Active
DSH050696AD	Child	DSH	Keck Hospital of USC	Keck Medicine of USC - Huntington Beach Treatment Center - Infusion	19582 Beach Boulevard	Huntington Beach	CA	Terminated
DSH050696AE	Child	DSH	Keck Hospital of USC	Keck Medicine of USC - Huntington Beach Healthcare Center - Hematology/Oncology	19582 Beach Boulevard	Huntington Beach	CA	Terminated
DSH050696AF	Child	DSH	Keck Hospital of USC	Arcadia Treatment Center (Arcadia Infusion) - Arcadia Infusion	125 West Huntington Drive	Arcadia	CA	Terminated
DSH050696AG	Child	DSH	Keck Hospital of USC	GI Liver Clinic - Gastroenterology	1510 San Pablo St	Los Angeles	CA	Active
DSH050696B	Child	DSH	Keck Hospital of USC	Transplant Clinic	1516 SAN PABLO STREET	LOS ANGELES	CA	Active
DSH050696C	Child	DSH	Keck Hospital of USC	Cystic Fibrosis	1510 San Pablo Street	LOS ANGELES	CA	Active
DSH050696D	Child	DSH	Keck Hospital of USC	CT Surgery Clinic	1520 SAN PABLO STREET, 4th FL	LOS ANGELES	CA	Active
DSH050696F	Child	DSH	Keck Hospital of USC	ESOPHAGEAL LAB	1500 SAN PABLO STREET	LOS ANGELES	CA	Active
DSH050696H	Child	DSH	Keck Hospital of USC	Sleep Disorders	1500 San Pablo Street, 3rd FL	Los Angeles	CA	Active
DSH050696K	Child	DSH	Keck Hospital of USC	CVTI	1520 San Pablo Street	Los Angeles	CA	Active
DSH050696L	Child	DSH	Keck Hospital of USC	Internal Medicine	1520 San Pablo Street, Suite 1000	Los Angeles,	CA	Active
DSH050696M	Child	DSH	Keck Hospital of USC	Neurosciences Clinic	1520 San Pablo Street, 3rd Floor	Los Angeles	CA	Active
DSH050696N	Child	DSH	Keck Hospital of USC	Ambulatory Surgery Center	1537 Norfolk Street	Los Angeles	CA	Active
DSH050696P	Child	DSH	Keck Hospital of USC	Surgery Clinic	1510 San Pablo Street, 5th Floor	Los Angeles	CA	Terminated
DSH050696Q	Child	DSH	Keck Hospital of USC	Keck Pasadena Clinic - Ophthalmology	625 South Fair Oaks Avenue	Pasadena	CA	Active
DSH050696R	Child	DSH	Keck Hospital of USC	PET Imaging Center	1510 San Pablo Street	Los Angeles	CA	Active
DSH050696S	Child	DSH	Keck Hospital of USC	Imaging Center	1520 San Pablo Street	Los Angeles	CA	Active
DSH050696T	Child	DSH	Keck Hospital of USC	Beverly Hills Clinic	9033 Wilshire Blvd	Beverly Hills	CA	Terminated
DSH050696U	Child	DSH	Keck Hospital of USC	Downtown Clinic	830 South Flower St.	LOS ANGELES	CA	Active
DSH050696V	Child	DSH	Keck Hospital of USC	ENT Clinic	1450 San Pablo	Los Angeles	CA	Active
DSH050696W	Child	DSH	Keck Hospital of USC	Pain Management	1520 San Pablo St.	Los Angeles	CA	Terminated
DSH050696X	Child	DSH	Keck Hospital of USC	Keck Pasadena Clinic - Main / Endocrinology, Cardiology, Dermatology, Rheumatology, Cardio-Thoracic Diagnostics, Family Medicine, Hepatobiliary & Pancreatic Surgery, Nutrition Medicine & Counseling, Vascular	625 S. Fair Oaks	Pasadena	CA	Active
DSH050696Y	Child	DSH	Keck Hospital of USC	USC Oncology Hematology	520 Superior Ave.	Newport Beach	CA	Terminated
DSH050696Z	Child	DSH	Keck Hospital of USC	USC Oncology Hematology Infusion	300 Old Newport Blvd	Newport Beach	CA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/17/2023 5:06:19 PM	8/22/2024 12:33:58 PM	8/22/2024 12:33 PM
Details	Last Recertification Date	Update	Recertification	8/29/2022 12:05:49 PM	8/17/2023 5:06:19 PM	8/17/2023 5:06 PM
Addresses	Shipping Address	Update	Change Request	Keck Hospital of USC-Arcadia Treatment Center 125 W. Huntington Drive Building A A300 Room 309 Arcadia, CA 91006	Keck Hospital of USC-Arcadia Treatment Center 125 W. Huntington Drive Building A A300 Room 309 Arcadia, CA 91007	1/19/2023 12:37 PM
Details	Last Recertification Date	Update	Recertification	9/13/2021 5:08:17 PM	8/29/2022 12:05:49 PM	8/29/2022 12:05 PM
Details	Last Recertification Date	Update	Recertification	8/25/2020 1:23:34 PM	9/13/2021 5:08:17 PM	9/13/2021 5:08 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013514199	1/11/2021 6:11 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	1/11/2021 6:11 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	8/25/2020 1:23 PM
Details	Last Recertification Date	Update	Recertification	9/11/2019 2:10:27 PM	8/25/2020 1:23:34 PM	8/25/2020 1:23 PM
Addresses	Shipping Address	Insert	Recertification		Keck Hospital of USC Pharmacy 1500 San Pablo Street Los Angeles, CA 90033	9/11/2019 2:10 PM
Addresses	Shipping Address	Insert	Recertification		Keck Hospital of USC-Arcadia Treatment Center 125 W. Huntington Drive Building A A300 Room 309 Arcadia, CA 91006	9/11/2019 2:10 PM
Details	Last Recertification Date	Update	Recertification	9/5/2018 12:19:52 PM	9/11/2019 2:10:27 PM	9/11/2019 2:10 PM
Contacts	Primary Contact	Update	Change Request	Gray, John Patrick Director, Enterprise 340B Operations Keck Medical Center of USC 3234428438	Azizian, Krist Chief Pharmacy Officer Keck Medicine of USC 3238653588	2/11/2019 5:47 PM
Contacts	Primary Contact	Update	Recertification	WING, EVELYN 340B MANAGER Keck Medicine of USC 3238653611	Gray, John Patrick Director, Enterprise 340B Operations Keck Medical Center of USC 3234428438	9/5/2018 12:19 PM
Details	Last Recertification Date	Update	Recertification	11/15/2017 3:40:52 PM	9/5/2018 12:19:52 PM	9/5/2018 12:19 PM
Addresses	Main Address	Update	Recertification	625 South Fair Oaks Avenue Suite 400 Pasadena, CA 91105	625 South Fair Oaks Avenue Room 4100 400 Pasadena, CA 91105	11/15/2017 3:40 PM
Details	Last Recertification Date	Update	Recertification	9/2/2016 12:00:00 AM	11/15/2017 3:40:52 PM	11/15/2017 3:40 PM
Contacts	Authorizing Official	Insert	Change Request		Hanners, Rod Chief Operating Officer Keck Medicine of USC 3234428677	9/25/2017 1:05 PM
Contacts	Primary Contact	Update		WING, EVELYN 340B MANAGER 3238653611	WING, EVELYN 340B MANAGER Keck Medicine of USC 3238653611	9/18/2017 5:49 PM
Contacts	Signed By	Insert			Evans, Scott CEO 3234428444-28745	9/27/2016 1:25 PM
Contacts	Primary Contact	Update		Chellamy, Caroline Director of Ambulatory Pharmacy 3238653545	WING, EVELYN 340B MANAGER 3238653611	9/5/2016 9:10 AM
Addresses	Main Address	Insert			625 South Fair Oaks Avenue Suite 400 Pasadena, CA 91105	9/2/2016 4:30 PM
Details	Last Recertification Date	Update		9/4/2015 12:00:00 AM	9/2/2016 12:00:00 AM	9/2/2016 4:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/4/2015 7:46 AM
Medicaid Billing	Medicaid: Number	Insert			HSP40696G	9/4/2015 7:46 AM
Medicaid Billing	Medicaid: State	Insert			CA	9/4/2015 7:46 AM
Details	Last Recertification Date	Update		9/10/2014 12:00:00 AM	9/4/2015 12:00:00 AM	9/4/2015 7:46 AM
Details	Entity Subname	Update		Keck Pasadena Clinic	Keck Pasadena Clinic - Ophthalmology	9/4/2015 7:46 AM
Addresses	Billing Address	Insert			Keck Hospital of USC 1500 San Pablo St. Los Angeles, CA 90033	3/19/2015 8:08 PM
Contacts	Primary Contact	Insert			Chellamy, Caroline Director of Ambulatory Pharmacy 3238653545	3/9/2015 10:53 AM
Details	Last Recertification Date	Update		9/12/2013 12:00:00 AM	9/10/2014 12:00:00 AM	9/10/2014 6:57 AM
Medicaid Billing	NPI: Number	Insert			1952546616	7/17/2014 9:52 AM
Details	Entity Subname	Update		Keck Medical Center of USC- Pasadena	Keck Pasadena Clinic	7/8/2014 7:49 AM
Details	Last Recertification Date	Update			9/12/2013 12:00:00 AM	9/12/2013 9:06 PM
Details	340B ID	Update		IS-DR-DSH050696Q	DSH050696Q	6/27/2012 2:09 PM
Dates	Participating Approval Date	Update			6/27/2012 12:00:00 AM	6/27/2012 2:09 PM
Details	State	Update		Pending	Active	6/27/2012 2:09 PM
Dates	Start Date	Update			7/1/2012 12:00:00 AM	6/27/2012 2:09 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	IS-DR-DSH050696Q	5/30/2012 2:55 PM
Details	Last Recertification Date	Insert				4/20/2012 4:29 PM
Details	Grant Number	Insert				4/20/2012 4:29 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	4/20/2012 4:29 PM
Details	Is Authorizing Official EHB Data	Insert				4/20/2012 4:29 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/20/2012 4:29 PM
Details	Medicare Provider Number	Insert			050696	4/20/2012 4:29 PM
Details	Entity Name	Insert			Keck Hospital of USC	4/20/2012 4:29 PM
Details	Program Code	Insert			DSH	4/20/2012 4:29 PM
Details	Entity Subname	Insert			Keck Medical Center of USC- Pasadena	4/20/2012 4:29 PM
Dates	Participating Approval Date	Insert				4/20/2012 4:29 PM
Details	State	Insert			Pending	4/20/2012 4:29 PM
Dates	Registration Date	Insert			4/20/2012 12:00:00 AM	4/20/2012 4:29 PM
Dates	Signed By Date	Insert			4/20/2012 12:00:00 AM	4/20/2012 4:29 PM
Dates	Start Date	Insert				4/20/2012 4:29 PM
Terminations	Termination Comments	Insert				4/20/2012 4:29 PM
Terminations	Termination Date	Insert				4/20/2012 4:29 PM
Terminations	Termination Effective Date	Insert				4/20/2012 4:29 PM
Terminations	Termination Reason	Insert				4/20/2012 4:29 PM