Covered Entity Details

CAN050660-03 USC Norris Cancer Hospital (Active) - information as of 5/13/2025 1:47:31 AM

Main Details

Name

USC Norris Cancer Hospital

Subdivision Name

Women's Specialty Care and Breast Center

Type

Free Standing Cancer Hospital

Rural

340B ID

CAN050660-03

Medicare Provider Number

050660

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/20/2017

Participating Start Date

1/1/2018

Participating Approval Date

10/24/2017

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

1516 San Pablo Street
3rd Floor
Los Angeles, CA 90033

Billing Address

Keck Hospital of USC-Norris Healthcare Center
1516 San Pablo Street
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		1770728438,1417554528

Shipping Addresses

Shipping Address 1

USC Kenneth Norris Jr. Cancer Hospital
1441 Eastlake Ave.
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
CAN050660-01	Child	CAN	USC Norris Cancer Hospital	Clinics	625 South Fair Oaks Avenue	Pasadena	CA	Active
CAN050660-02	Child	CAN	USC Norris Cancer Hospital	Urology - NCH Urology	1516 SAN PABLO STREET	Los Angeles	CA	Active
CAN050660-03	Child	CAN	USC Norris Cancer Hospital	Women's Specialty Care and Breast Center	1516 San Pablo Street	Los Angeles	CA	Active
CAN050660-04	Child	CAN	USC Norris Cancer Hospital	USC Cancer Center LA - Oncology/Infusion	500 S. Virgil Ave Suite 502	Los Angeles	CA	Active
CAN050660-05	Child	CAN	USC Norris Cancer Hospital	Buena Park - Buena Park Infusion	5832 Beach Blvd Suite 201	Buena Park	CA	Active
CAN050660-06	Child	CAN	USC Norris Cancer Hospital	Keck Medicine of USC - Arcadia Clinic - Hematology/Oncology - Hematology, Oncology, Sarcoma, Dermatology, Rheumatology, Hepatobiliary, Otolaryngology	125 W. Huntington Dr	Arcadia	CA	Active
CAN050660-07	Child	CAN	USC Norris Cancer Hospital	Keck Medicine of USC - Arcadia Radiation Oncology - Radiation Oncology	125 W. Huntington Drive	Arcadia	CA	Active
CAN050660-08	Child	CAN	USC Norris Cancer Hospital	Keck Medicine of USC - Arcadia Treatment Center - Arcadia Infusion Center - Hematology, Oncology,	125 W. Huntington Drive	Arcadia	CA	Active
CAN050660-09	Child	CAN	USC Norris Cancer Hospital	Keck Medicine of USC - Huntington Beach Healthcare Center - Hematology, Oncology, Neurology	19582 Beach Blvd.	Huntington Beach	CA	Terminated
CAN050660-10	Child	CAN	USC Norris Cancer Hospital	Keck Medicine of USC - USC Norris Oncology/Hematology Newport Beach - Oncology, Hematology, Cancer Therapy, Blood Disorders	330 Old Newport Blvd	Newport Beach	CA	Active
CAN050660-11	Child	CAN	USC Norris Cancer Hospital	Keck Medicine of USC Norris Treatment Center Newport Beach - Infusion Center - Chemotherapy, Oncology, Hematology, Infusion Therapy	330 Old Newport Blvd.	Newport Beach	CA	Active
CAN050660-12	Child	CAN	USC Norris Cancer Hospital	Keck Medicine of USC - Huntington Beach Treatment Center - Infusion Center - Hematology, Oncology, Neurology	19582 Beach Blvd.	Huntington Beach	CA	Terminated
CAN050660-13	Child	CAN	USC Norris Cancer Hospital	USC KENNETH NORRIS JR CANCER HOSPIT - Radiation Oncology	25751 MCBEAN PKWY	SANTA CLARITA	CA	Active
CAN050660-14	Child	CAN	USC Norris Cancer Hospital	Keck Medicine of USC - Santa Clarita Treatment Center and Infusion Center - Multi-Specialty	25751 McBean Pkwy	Santa Clarita	CA	Active
CAN050660-15	Child	CAN	USC Norris Cancer Hospital	Buena Park Radiation Oncology - Radiation Oncology and Urology	5832 Beach Blvd	Buena Park	CA	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/17/2023 4:59:02 PM	8/22/2024 12:29:44 PM	8/22/2024 12:29 PM
Details	Last Recertification Date	Update	Recertification	8/29/2022 12:02:39 PM	8/17/2023 4:59:02 PM	8/17/2023 4:59 PM
Addresses	Shipping Address	Update	Change Request	USC Kenneth Norris Jr. Cancer Hospital 1441 Eastlake Ave. Room 1355, First Floor Los Angeles, CA 90033	USC Kenneth Norris Jr. Cancer Hospital 1441 Eastlake Ave. Los Angeles, CA 90033	1/19/2023 7:21 AM
Details	Last Recertification Date	Update	Recertification	9/13/2021 4:59:07 PM	8/29/2022 12:02:39 PM	8/29/2022 12:02 PM
Details	Last Recertification Date	Update	Recertification	8/25/2020 1:23:52 PM	9/13/2021 4:59:07 PM	9/13/2021 4:59 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1417554528	1/11/2021 6:04 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	1/11/2021 6:04 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	8/25/2020 1:23 PM
Details	Last Recertification Date	Update	Recertification	9/11/2019 1:38:19 PM	8/25/2020 1:23:52 PM	8/25/2020 1:23 PM
Addresses	Shipping Address	Delete	Recertification	Keck Hospital of USC-Norris Healthcare Center 1516 San Pablo Street 3403 Los Angeles, CA 90033		9/11/2019 1:38 PM
Addresses	Shipping Address	Insert	Recertification		USC Kenneth Norris Jr. Cancer Hospital 1441 Eastlake Ave. Room 1355, First Floor Los Angeles, CA 90033	9/11/2019 1:38 PM
Details	Last Recertification Date	Update	Recertification	9/5/2018 12:11:20 PM	9/11/2019 1:38:19 PM	9/11/2019 1:38 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 4:56 PM
Contacts	Primary Contact	Update	Recertification	Wing, Evelyn 340B Manager Keck Medical Center of USC 3238653611	Gray, John Patrick Director, Enterprise 340B Operations Keck Medical Center of USC 3234428438	9/5/2018 12:11 PM
Details	Last Recertification Date	Update	Recertification		9/5/2018 12:11:20 PM	9/5/2018 12:11 PM
Addresses	Main Address	Update	Change Request	1441 Eastlake Avenue 1382 Los Angeles, CA 90033	1516 San Pablo Street 3rd Floor Los Angeles, CA 90033	1/5/2018 3:11 PM
Addresses	Billing Address	Insert	Change Request		Keck Hospital of USC-Norris Healthcare Center 1516 San Pablo Street Los Angeles, CA 90033	1/5/2018 3:11 PM
Addresses	Shipping Address	Insert	Change Request		Keck Hospital of USC-Norris Healthcare Center 1516 San Pablo Street 3403 Los Angeles, CA 90033	1/5/2018 3:11 PM
Details	Entity Subname	Update	Change Request	Breast Center - Breast Center Clinic	Women's Specialty Care and Breast Center	1/5/2018 3:11 PM
Details	State	Update		Approved	Active	1/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		Hanners, Rod Chief Operating Officer Keck Medicine of USC 3234428677	10/24/2017 9:26 AM
Details	340B ID	Update	New Registration		CAN050660-03	10/24/2017 9:26 AM
Details	Entity Subname	Update	New Registration	Breast Center	Breast Center - Breast Center Clinic	10/24/2017 9:26 AM
Dates	Participating Approval Date	Update	New Registration		10/24/2017 9:26:16 AM	10/24/2017 9:26 AM
Details	State	Update	New Registration	Pending	Approved	10/24/2017 9:26 AM
Dates	Signed By Date	Update	New Registration		10/20/2017 6:13:55 PM	10/24/2017 9:26 AM
Dates	Start Date	Update	New Registration		1/1/2018 12:00:00 AM	10/24/2017 9:26 AM
Addresses	Main Address	Insert	New Registration		1441 Eastlake Avenue 1382 Los Angeles, CA 90033	10/20/2017 6:13 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770728438	10/20/2017 6:13 PM
Contacts	Primary Contact	Insert	New Registration		Wing, Evelyn 340B Manager Keck Medical Center of USC 3238653611	10/20/2017 6:13 PM
Contacts	Authorizing Official	Insert	New Registration		Hanners, Rod Chief Operating Officer Keck Medicine of USC 3234428677	10/20/2017 6:13 PM
Details	Last Recertification Date	Insert	New Registration			10/20/2017 6:13 PM
Details	Grant Number	Insert	New Registration			10/20/2017 6:13 PM
Details	340B ID	Insert	New Registration			10/20/2017 6:13 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/20/2017 6:13 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/20/2017 6:13 PM
Details	Medicare Provider Number	Insert	New Registration		050660	10/20/2017 6:13 PM
Details	Entity Name	Insert	New Registration		USC Norris Cancer Hospital	10/20/2017 6:13 PM
Details	Program Code	Insert	New Registration		CAN	10/20/2017 6:13 PM
Details	Entity Subname	Insert	New Registration		Breast Center	10/20/2017 6:13 PM
Dates	Participating Approval Date	Insert	New Registration			10/20/2017 6:13 PM
Details	State	Insert	New Registration		Pending	10/20/2017 6:13 PM
Dates	Registration Date	Insert	New Registration		10/20/2017 6:13:51 PM	10/20/2017 6:13 PM
Dates	Signed By Date	Insert	New Registration			10/20/2017 6:13 PM
Dates	Start Date	Insert	New Registration			10/20/2017 6:13 PM
Terminations	Termination Comments	Insert	New Registration			10/20/2017 6:13 PM
Terminations	Termination Date	Insert	New Registration			10/20/2017 6:13 PM
Terminations	Termination Effective Date	Insert	New Registration			10/20/2017 6:13 PM
Terminations	Termination Reason	Insert	New Registration			10/20/2017 6:13 PM