Covered Entity Details

DSH050373BZ LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - Los Angeles General Medical Center (Active) - information as of 5/3/2025 11:26:06 PM

Main Details

Name

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

Subdivision Name

Los Angeles General Medical Center / MEDICINE INFUSION

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050373BZ

Medicare Provider Number

050373

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/12/2018

Participating Start Date

1/1/2019

Participating Approval Date

10/23/2018

Last Recertification Date

8/20/2024

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
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	HSC30373W	1285647933,1124152954,1891810883,1598773715,1528078573

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
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
Details	Last Recertification Date	Update	Recertification	8/26/2023 1:13:05 PM	8/20/2024 9:18:42 AM	8/20/2024 9:18 AM
Details	Entity Subname	Update	Recertification	MEDICINE INFUSION - MEDICINE INFUSION	Los Angeles General Medical Center / MEDICINE INFUSION	8/20/2024 9:18 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
Contacts	Signed By	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 1:13 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/26/2023 1:13 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1528078573	8/26/2023 1:13 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/26/2023 1:13 PM
Details	Last Recertification Date	Update	Recertification	8/31/2022 10:34:10 AM	8/26/2023 1:13:05 PM	8/26/2023 1:13 PM
Details	Last Recertification Date	Update	Recertification	8/25/2021 4:01:42 PM	8/31/2022 10:34:10 AM	8/31/2022 10:34 AM
Details	Last Recertification Date	Update	Recertification	8/20/2020 10:06:51 AM	8/25/2021 4:01:42 PM	8/25/2021 4:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/20/2020 10:06 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		HSC30373W	8/20/2020 10:06 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	8/20/2020 10:06 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1124152954	8/20/2020 10:06 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/20/2020 10:06 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1891810883	8/20/2020 10:06 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/20/2020 10:06 AM
Medicaid Billing	NPI: State	Update	Recertification		CA	8/20/2020 10:06 AM
Details	Last Recertification Date	Update	Recertification	8/20/2019 3:48:11 PM	8/20/2020 10:06:51 AM	8/20/2020 10:06 AM
Details	Last Recertification Date	Update	Recertification		8/20/2019 3:48:11 PM	8/20/2019 3:48 PM
Details	State	Update		Approved	Active	1/1/2019 12:05 AM
Contacts	Signed By	Insert	New Registration		Spellberg, Brad CMO LAC+USC Medical Center 3234292800	10/23/2018 10:59 AM
Details	340B ID	Update	New Registration		DSH050373BZ	10/23/2018 10:59 AM
Details	Entity Name	Update	New Registration	LAC+USC MEDICAL CENTER	LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES - USC MEDICAL CENTER	10/23/2018 10:59 AM
Details	Entity Subname	Update	New Registration	MEDICINE INFUSION	MEDICINE INFUSION - MEDICINE INFUSION	10/23/2018 10:59 AM
Dates	Participating Approval Date	Update	New Registration		10/23/2018 10:59:43 AM	10/23/2018 10:59 AM
Details	State	Update	New Registration	Pending	Approved	10/23/2018 10:59 AM
Dates	Signed By Date	Update	New Registration		10/13/2018 12:53:54 PM	10/23/2018 10:59 AM
Dates	Start Date	Update	New Registration		1/1/2019 12:00:00 AM	10/23/2018 10:59 AM
Addresses	Main Address	Insert	New Registration		2010 Zonal Ave Los Angeles, CA 90033	10/12/2018 5:18 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1285647933	10/12/2018 5:18 PM
Contacts	Primary Contact	Insert	New Registration		Bannister, Beatrisa Pharmacy Service Chief LAC+USC Medical Center 3234094280	10/12/2018 5:18 PM
Contacts	Authorizing Official	Insert	New Registration		Spellberg, Brad CMO LAC+USC Medical Center 3234292800	10/12/2018 5:18 PM
Details	Last Recertification Date	Insert	New Registration			10/12/2018 5:18 PM
Details	Grant Number	Insert	New Registration			10/12/2018 5:18 PM
Details	340B ID	Insert	New Registration			10/12/2018 5:18 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/12/2018 5:18 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/12/2018 5:18 PM
Details	Medicare Provider Number	Insert	New Registration		050373	10/12/2018 5:18 PM
Details	Entity Name	Insert	New Registration		LAC+USC MEDICAL CENTER	10/12/2018 5:18 PM
Details	Program Code	Insert	New Registration		DSH	10/12/2018 5:18 PM
Details	Entity Subname	Insert	New Registration		MEDICINE INFUSION	10/12/2018 5:18 PM
Dates	Participating Approval Date	Insert	New Registration			10/12/2018 5:18 PM
Details	State	Insert	New Registration		Pending	10/12/2018 5:18 PM
Dates	Registration Date	Insert	New Registration		10/12/2018 5:18:10 PM	10/12/2018 5:18 PM
Dates	Signed By Date	Insert	New Registration			10/12/2018 5:18 PM
Dates	Start Date	Insert	New Registration			10/12/2018 5:18 PM
Terminations	Termination Comments	Insert	New Registration			10/12/2018 5:18 PM
Terminations	Termination Date	Insert	New Registration			10/12/2018 5:18 PM
Terminations	Termination Effective Date	Insert	New Registration			10/12/2018 5:18 PM
Terminations	Termination Reason	Insert	New Registration			10/12/2018 5:18 PM