Covered Entity Details

DSH050373BQ LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center (Active) - information as of 6/9/2025 11:02:21 PM

Main Details

Name

LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center

Subdivision Name

LA General Medical Center / Hematology Infusion

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050373BQ

Medicare Provider Number

050373

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/9/2015

Participating Start Date

1/1/2016

Participating Approval Date

11/19/2015

Last Recertification Date

8/18/2024

Contacts

Authorizing Official

Los Angeles General Medical Center
Brad Spellberg, CMO
(323) 409-2130

Primary Contact

LAC+USC Medical Center
Beatrisa Bannister, Pharmacy Service Chief
(323) 409-4280

Addresses

Street Address

2010 Zonal Ave
Los Angeles, CA 90033

Billing Address

Los Angeles County Department of Health Services - LA General Medical Center
2051 Marengo 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	HSC30373W	1124152954,1285647933,1891810883,1598773715,1528078573

Shipping Addresses

Shipping Address 1

Outpatient Pharmacy
2010 Zonal Avenue
Room 2P82
Los Angeles, CA 90033

Shipping Address 2

Clinic Tower Pharmacy
1100 North State Street
Room A1C109
Los Angeles, CA 90033

Shipping Address 3

Rx e-fill Solutions
28341 Constellation Rd
Santa Clarita, CA 91355

Shipping Address 4

LA General Medical Center Pharmacy
2051 Marengo St
Room B2A100
Los Angeles, CA 90033

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
DSH050373AA	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Rand Schrader Infectious Disease	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373AB	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Hepatitis Clinic	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373AC	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Maternal Child Adolescent Obstetrics	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373AD	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Maternal Child Adolescent Primary Care	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373AE	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Maternal Child Adolescent Neurology	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373AF	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Primary Care East	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373AG	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Maternal Child Adolescent Mental Health	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373AH	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Maternal Child Adolescent Gynecology	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373AJ	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Maternal Child Adolescent Infectious Disease	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373AK	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LAC+USC Medical Center / Dermatology Surgery	1300 North Mission Road	Los Angeles	CA	Terminated
DSH050373AL	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Rheumatology	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373AM	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LAC+USC Medical Center / Liver Clinic	2010 Zonal Ave	Los Angeles	CA	Terminated
DSH050373AN	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LAC+USC Medical Center / Gynecology Oncology Post Operative	2010 Zonal Ave	Los Angeles	CA	Terminated
DSH050373AP	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LAC+USC Medical Center / Gynecology Oncology Molar Pregnancy	2010 Zonal Ave	Los Angeles	CA	Terminated
DSH050373AQ	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Gynecology Oncology	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373AR	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LAC+USC Medical Center / Pediatric Surgery	2010 Zonal Ave	Los Angeles	CA	Terminated
DSH050373AS	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LAC+USC Medical Center / Gynecology Oncology Abnormal Results	2010 Zonal Ave	Los Angeles	CA	Terminated
DSH050373AT	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LAC+USC Medical Center / Gynecology Oncology Chemotherapy	2010 Zonal Ave	Los Angeles	CA	Terminated
DSH050373AU	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LAC+USC Medical Center / Pediatric Developmental Disability	2010 Zonal Ave	Los Angeles	CA	Terminated
DSH050373AV	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LAC+USC Medical Center / Dermatology Phototherapy Clinic	1300 North Mission Road	Los Angeles	CA	Terminated
DSH050373AW	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Pediatric Genetics	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373AX	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Pediatric Urology	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373AY	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LAC+USC Medical Center / Myelomeningocele	2010 Zonal Ave	Los Angeles	CA	Terminated
DSH050373AZ	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Pediatric Neurology	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373BA	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Pediatric Continuity Care	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373BB	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Pediatric Cardiology	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373BC	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Allergy	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373BD	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Special Care Pulmonology	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373BE	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Pediatric Renal	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373BF	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Pediatric Gastroenterology	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373BG	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Pediatric Oncology	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373BH	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Pediatric Endocrine	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373BJ	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Pediatric Diabetes	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373BK	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Gastro	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373BL	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Geriatric	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373BM	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Podiatry	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373BN	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Primary Care West	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373BP	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LAC+USC Medical Center / Anticoagulation	2010 Zonal Ave	Los Angeles	CA	Terminated
DSH050373BQ	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Hematology Infusion	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373BR	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LAC+USC Medical Center / Child/Adolescent Psychiatric	2010 Zonal Ave	Los Angeles	CA	Terminated
DSH050373BS	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Oncology Infusion	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373BT	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Violence Intervention Program (VIP)	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373BU	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	Los Angeles Genral Medical Center / DERMATOLOGY	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373BV	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / DERMATOLOGY INFUSION	1300 N MISSION RD	LOS ANGELES	CA	Active
DSH050373BW	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / DIABETES CLINIC	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373BX	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / ENDOCRINE INFUSION	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373BY	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / GASTRO INFUSION	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373BZ	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	Los Angeles General Medical Center / MEDICINE INFUSION	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373CA	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / NEPHROLOGY INFUSION	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373CB	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / MEDICINE INFUSION RAND SCHRADER	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373CC	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / NEUROLOGY INFUSION	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373CD	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	OBSTETRICS ONCOLOGY - OBSTETRICS ONCOLOGY	2010 Zonal Ave	Los Angeles	CA	Terminated
DSH050373CE	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / OPHTHALMOLOGY INFUSION	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373CF	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / PEDIATRIC ALLERGY	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373CG	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / PEDIATRIC DERMATOLOGY	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373CH	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / PEDIATRIC INFUSION/HEM	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373CJ	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / PEDS PREEMIE	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373CK	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / PEDS PRIMARY CARE PREEM	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373CL	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / RHEUMATOLOGY INFUSION	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373CM	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	Los Angeles General Medical Center / HEMA INFUSION RAND SCHRADER	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373CN	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / GASTRO INFUSION RAND SCHRADER	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373CP	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / NEUROLOGY INFUSION RAND SCHRADER	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373D	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Rand Schrader Liver Clinic	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373E	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LAC+USC Medical Center / Dermatology Surgery	1300 North Mission Rd	Los Angeles	CA	Terminated
DSH050373F	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LAC+USC Medical Center / Managed Care Adult Primary Care	2010 Zonal Ave	Los Angeles	CA	Terminated
DSH050373G	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Nephrology Clinic	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373H	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Med / Peds Family Center Continuity of Care	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373J	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LAC+USC Medical Center / Community-Based Assessment and Treatment Center	2010 Zonal Ave	Los Angeles	CA	Terminated
DSH050373K	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LAC+USC Medical Center / Rand Schrader Medication Compliance	1300 North Mission Rd	Los Angeles	CA	Terminated
DSH050373L	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Infectious Disease	2010 Zonal Ave	Los Angeles	CA	Active
DSH050373M	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Maternal Child Adolescent Pediatric Primary Care	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373N	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Asthma Mobile Unit	1200N STATE ST	LOS ANGELES	CA	Active
DSH050373P	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Rand Schrader Mental Health	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373Q	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LAC+USC Medical Center / Rand Schrader Neuropsychology	1300 North Mission Rd	Los Angeles	CA	Terminated
DSH050373R	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Rand Schrader Primary Care	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373S	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LAC+USC Medical Center / Rand Schrader Rectal Clinic	1300 North Mission Rd	Los Angeles	CA	Terminated
DSH050373T	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Rand Schrader Pulmonary Clinic	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373U	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Rand Schrader Neurology	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373V	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Rand Schrader Gastro Clinic	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373W	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Rand Schrader Oncology	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373X	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Rand Schrader Hematology	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373Y	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LA General Medical Center / Rand Schrader Gynecology	1300 North Mission Rd	Los Angeles	CA	Active
DSH050373Z	Child	DSH	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	LAC+USC Medical Center / Rand Schrader Dermatology	1300 North Mission Rd	Los Angeles	CA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Insert	Recertification		LA General Medical Center Pharmacy 2051 Marengo St Room B2A100 Los Angeles, CA 90033	8/18/2024 9:42 AM
Addresses	Billing Address	Update	Recertification	Los Angeles CountyDepartment of Health Services - USC Medical Center 1200 North State Street Los Angeles, CA 90033	Los Angeles County Department of Health Services - LA General Medical Center 2051 Marengo St Los Angeles, CA 90033	8/18/2024 9:42 AM
Addresses	Shipping Address	Delete	Recertification	LAC + USC Medical Center Pharmacy 1200 North State Street Room B2A100 Los Angeles, CA 90033		8/18/2024 9:42 AM
Details	Last Recertification Date	Update	Recertification	8/26/2023 2:58:39 PM	8/18/2024 9:42:25 AM	8/18/2024 9:42 AM
Details	Entity Subname	Update	Recertification	LAC+USC Medical Center / Hematology Infusion	LA General Medical Center / Hematology Infusion	8/18/2024 9:42 AM
Details	Entity Name	Update	Change Request	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - USC MEDICAL CENTER	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center	3/7/2024 12:46 PM
Contacts	Authorizing Official	Update	Profile Change Request	Spellberg, Brad CMO LAC+USC Medical Center 3234292800	Spellberg, Brad CMO Los Angeles General Medical Center 3234092130	8/28/2023 6:12 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1598773715	8/26/2023 2:58 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/26/2023 2:58 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1528078573	8/26/2023 2:58 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/26/2023 2:58 PM
Details	Last Recertification Date	Update	Recertification	8/31/2022 10:41:10 AM	8/26/2023 2:58:39 PM	8/26/2023 2:58 PM
Details	Last Recertification Date	Update	Recertification	8/25/2021 4:12:59 PM	8/31/2022 10:41:10 AM	8/31/2022 10:41 AM
Details	Last Recertification Date	Update	Recertification	8/20/2020 10:00:50 AM	8/25/2021 4:12:59 PM	8/25/2021 4:12 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1124152954	8/20/2020 10:00 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/20/2020 10:00 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1285647933	8/20/2020 10:00 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/20/2020 10:00 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1891810883	8/20/2020 10:00 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/20/2020 10:00 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1285647933 ( )		8/20/2020 10:00 AM
Details	Last Recertification Date	Update	Recertification	8/20/2019 3:52:32 PM	8/20/2020 10:00:50 AM	8/20/2020 10:00 AM
Details	Last Recertification Date	Update	Recertification	8/16/2018 11:00:19 AM	8/20/2019 3:52:32 PM	8/20/2019 3:52 PM
Contacts	Authorizing Official	Update	Profile Change Request	Spellberg, Brad CEO LAC+USC Medical Center 3234292800	Spellberg, Brad CMO LAC+USC Medical Center 3234292800	8/27/2018 4:51 PM
Details	Last Recertification Date	Update	Recertification	11/4/2017 5:24:10 PM	8/16/2018 11:00:19 AM	8/16/2018 11:00 AM
Details	Last Recertification Date	Update	Recertification	8/16/2016 12:00:00 AM	11/4/2017 5:24:10 PM	11/4/2017 5:24 PM
Contacts	Authorizing Official	Update		Spellberg, Brad CEO 3234292800	Spellberg, Brad CEO LAC+USC Medical Center 3234292800	10/19/2017 1:46 PM
Contacts	Primary Contact	Update		Bannister, Beatrisa Pharmacy Service Chief 3234094280	Bannister, Beatrisa Pharmacy Service Chief LAC+USC Medical Center 3234094280	10/18/2017 11:44 AM
Contacts	Primary Contact	Insert			Bannister, Beatrisa Pharmacy Service Chief 3234094280	7/27/2017 10:36 AM
Contacts	Authorizing Official	Update		Bilitch, Bonnie CEO 3234292800	Spellberg, Brad CEO 3234292800	7/27/2017 10:36 AM
Contacts	Signed By	Insert			Castillo, Daniel CEO 3234292800	7/27/2017 10:36 AM
Addresses	Main Address	Insert			2010 Zonal Ave Los Angeles, CA 90033	7/27/2017 10:33 AM
Addresses	Billing Address	Insert			Los Angeles CountyDepartment of Health Services - USC Medical Center 1200 North State Street Los Angeles, CA 90033	7/27/2017 10:33 AM
Addresses	Shipping Address	Insert			Clinic Tower Pharmacy 1100 North State Street Room A1C109 Los Angeles, CA 90033	7/27/2017 10:33 AM
Addresses	Shipping Address	Insert			Outpatient Pharmacy 2010 Zonal Avenue Room 2P82 Los Angeles, CA 90033	7/27/2017 10:33 AM
Addresses	Shipping Address	Insert			LAC + USC Medical Center Pharmacy 1200 North State Street Room B2A100 Los Angeles, CA 90033	7/27/2017 10:33 AM
Addresses	Shipping Address	Insert			Rx e-fill Solutions 28341 Constellation Rd Santa Clarita, CA 91355	7/27/2017 10:33 AM
Contacts	Authorizing Official	Insert			Bilitch, Bonnie CEO 3234292800	6/15/2017 1:58 PM
Details	Last Recertification Date	Update			8/16/2016 12:00:00 AM	8/16/2016 2:25 PM
Dates	Participating Approval Date	Update			11/19/2015 12:00:00 AM	11/19/2015 10:02 AM
Details	State	Update		Pending	Active	11/19/2015 10:02 AM
Dates	Start Date	Update			1/1/2016 12:00:00 AM	11/19/2015 10:02 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_54934	DSH050373BQ	10/27/2015 2:53 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_54934	10/9/2015 5:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/9/2015 5:13 PM
Medicaid Billing	Medicaid: Number	Insert			HSC30373W	10/9/2015 5:13 PM
Medicaid Billing	Medicaid: State	Insert			CA	10/9/2015 5:13 PM
Medicaid Billing	NPI: Number	Insert			1285647933	10/9/2015 5:13 PM
Details	Last Recertification Date	Insert				10/9/2015 5:13 PM
Details	Grant Number	Insert				10/9/2015 5:13 PM
Details	340B ID	Insert				10/9/2015 5:13 PM
Details	Is Authorizing Official EHB Data	Insert				10/9/2015 5:13 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/9/2015 5:13 PM
Details	Medicare Provider Number	Insert			050373	10/9/2015 5:13 PM
Details	Entity Name	Insert			LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - USC MEDICAL CENTER	10/9/2015 5:13 PM
Details	Program Code	Insert			DSH	10/9/2015 5:13 PM
Details	Entity Subname	Insert			LAC+USC Medical Center / Hematology Infusion	10/9/2015 5:13 PM
Dates	Participating Approval Date	Insert				10/9/2015 5:13 PM
Details	State	Insert			Pending	10/9/2015 5:13 PM
Dates	Registration Date	Insert			10/9/2015 12:00:00 AM	10/9/2015 5:13 PM
Dates	Signed By Date	Insert			10/9/2015 12:00:00 AM	10/9/2015 5:13 PM
Dates	Start Date	Insert				10/9/2015 5:13 PM
Terminations	Termination Comments	Insert				10/9/2015 5:13 PM
Terminations	Termination Date	Insert				10/9/2015 5:13 PM
Terminations	Termination Effective Date	Insert				10/9/2015 5:13 PM
Terminations	Termination Reason	Insert				10/9/2015 5:13 PM