Covered Entity Details

DSH050353B PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE (Terminated) - information as of 5/25/2025 1:17:14 AM

Main Details

Name

PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE

Subdivision Name

LCMH Med Therapy Mgmt Clinic - Phamacotherapy

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050353B

Medicare Provider Number

050353

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

7/13/2018

Participating Start Date

10/1/2018

Participating Approval Date

8/3/2018

Last Recertification Date

9/1/2020

Termination Date
Termination Reason

10/1/2021
Business decision by the Covered Entity

Contacts

Authorizing Official

Providence Health & Services Little Company of Mary Medical Centers San Pedro and Torrance
John Fleming Goeders, Chief Financial Officer
(310) 829-8411

Primary Contact

Providence Little Company of Mary Medical Center
Muno Bholat, Director of Pharmacy
(310) 303-5722

Addresses

Street Address

4101 TORRANCE BLVD
TORRANCE, CA 90503

Billing Address
Same as Street Address

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	hsc30353	1902844988

Shipping Addresses

Same as Street Address

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
DSH050353A	Child	DSH	PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE	OUTPATIENT REHABILITATION / Physical Therapy	21135 HAWTHORNE BLVD	TORRANCE	CA	Active
DSH050353B	Child	DSH	PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE	LCMH Med Therapy Mgmt Clinic - Phamacotherapy	4101 TORRANCE BLVD	TORRANCE	CA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2021 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		10/1/2021 12:00:00 AM	9/9/2021 5:39 PM
Details	State	Update	Recertification	Active	To Be Terminated	9/9/2021 5:39 PM
Terminations	Termination Comments	Update	Recertification		Clinic is within 4 walls of the hospital and does not require registration	9/9/2021 5:39 PM
Terminations	Termination Date	Update	Recertification		10/1/2021 12:00:00 AM	9/9/2021 5:39 PM
Terminations	Termination Effective Date	Update	Recertification		10/1/2021 12:00:00 AM	9/9/2021 5:39 PM
Terminations	Termination Reason	Update	Recertification		Business decision by the Covered Entity	9/9/2021 5:39 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/1/2020 4:14 PM
Details	Last Recertification Date	Update	Recertification	8/20/2019 12:37:57 PM	9/1/2020 4:14:59 PM	9/1/2020 4:14 PM
Contacts	Authorizing Official	Update	AO Change Request	Wang, Ted CFO LCM Torrance and San Pedro 3103036114	Goeders, John Fleming Chief Financial Officer Providence Health & Services Little Company of Mary Medical Centers San Pedro and Torrance 3108298411	7/7/2020 8:00 AM
Details	Last Recertification Date	Update	Recertification		8/20/2019 12:37:57 PM	8/20/2019 12:37 PM
Details	State	Update		Approved	Active	10/1/2018 12:05 AM
Contacts	Signed By	Insert	New Registration		Wang, Ted CFO LCM Torrance and San Pedro 3103036114	8/3/2018 4:13 PM
Details	340B ID	Update	New Registration		DSH050353B	8/3/2018 4:13 PM
Details	Entity Subname	Update	New Registration	LCMH Med Therapy Mgmt Clinic	LCMH Med Therapy Mgmt Clinic - Phamacotherapy	8/3/2018 4:13 PM
Dates	Participating Approval Date	Update	New Registration		8/3/2018 4:13:59 PM	8/3/2018 4:13 PM
Details	State	Update	New Registration	Pending	Approved	8/3/2018 4:13 PM
Dates	Signed By Date	Update	New Registration		7/15/2018 6:17:00 PM	8/3/2018 4:13 PM
Dates	Start Date	Update	New Registration		10/1/2018 12:00:00 AM	8/3/2018 4:13 PM
Addresses	Main Address	Insert	New Registration		4101 TORRANCE BLVD TORRANCE, CA 90503	7/13/2018 7:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/13/2018 7:57 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		hsc30353	7/13/2018 7:57 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	7/13/2018 7:57 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1902844988	7/13/2018 7:57 PM
Contacts	Primary Contact	Insert	New Registration		Bholat, Muno Director of Pharmacy Providence Little Company of Mary Medical Center 3103035722	7/13/2018 7:57 PM
Contacts	Authorizing Official	Insert	New Registration		Wang, Ted CFO LCM Torrance and San Pedro 3103036114	7/13/2018 7:57 PM
Details	Last Recertification Date	Insert	New Registration			7/13/2018 7:57 PM
Details	Grant Number	Insert	New Registration			7/13/2018 7:57 PM
Details	340B ID	Insert	New Registration			7/13/2018 7:57 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/13/2018 7:57 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/13/2018 7:57 PM
Details	Medicare Provider Number	Insert	New Registration		050353	7/13/2018 7:57 PM
Details	Entity Name	Insert	New Registration		PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE	7/13/2018 7:57 PM
Details	Program Code	Insert	New Registration		DSH	7/13/2018 7:57 PM
Details	Entity Subname	Insert	New Registration		LCMH Med Therapy Mgmt Clinic	7/13/2018 7:57 PM
Dates	Participating Approval Date	Insert	New Registration			7/13/2018 7:57 PM
Details	State	Insert	New Registration		Pending	7/13/2018 7:57 PM
Dates	Registration Date	Insert	New Registration		7/13/2018 7:57:34 PM	7/13/2018 7:57 PM
Dates	Signed By Date	Insert	New Registration			7/13/2018 7:57 PM
Dates	Start Date	Insert	New Registration			7/13/2018 7:57 PM
Terminations	Termination Comments	Insert	New Registration			7/13/2018 7:57 PM
Terminations	Termination Date	Insert	New Registration			7/13/2018 7:57 PM
Terminations	Termination Effective Date	Insert	New Registration			7/13/2018 7:57 PM
Terminations	Termination Reason	Insert	New Registration			7/13/2018 7:57 PM