Covered Entity Details

CAN050660-09 USC Norris Cancer Hospital (Terminated) - information as of 4/24/2025 12:00:22 AM

Main Details

Name

USC Norris Cancer Hospital

Subdivision Name

Keck Medicine of USC - Huntington Beach Healthcare Center - Hematology, Oncology, Neurology

Type

Free Standing Cancer Hospital

Rural

340B ID

CAN050660-09

Medicare Provider Number

050660

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/14/2022

Participating Start Date

7/1/2022

Participating Approval Date

4/21/2022

Last Recertification Date

8/17/2023

Termination Date
Termination Reason

1/1/2024
Business decision by the Covered Entity

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

19582 Beach Blvd.
Suite 206
Huntington Beach, CA 92648

Billing Address

USC Norris Cancer Hospital
1441 Eastlake Avenue
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 Norris Cancer Hospital
1441 Eastlake Avenue
Los Angeles, CA 90033

Shipping Address 2

Keck Medicine of USC - Huntington Beach Healthcare Center
19582 Beach Blvd.
Suite 206
Huntington Beach, CA 92648

Shipping Address 3

KECK HOSPITAL OF USC - HUNTINGTON BEACH TREATMENT CENTER
19582 BEACH BLVD STE 115L
Huntington Beach, CA 92648

Shipping Address 4

Keck Hospital of USC - Newport Pharmacy
330 Old Newport Blvd.
RM 170
Newport Beach, CA 92663

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	State	Update		To Be Terminated	Terminated	1/1/2024 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		7/21/2023 12:00:00 AM	10/16/2023 2:13 PM
Details	State	Update	Termination Request	Active	To Be Terminated	10/16/2023 2:13 PM
Terminations	Termination Date	Update	Termination Request		1/1/2024 12:00:00 AM	10/16/2023 2:13 PM
Terminations	Termination Effective Date	Update	Termination Request		8/14/2023 12:00:00 AM	10/16/2023 2:13 PM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	10/16/2023 2:13 PM
Details	Last Recertification Date	Update	Recertification	8/29/2022 11:59:45 AM	8/17/2023 5:00:47 PM	8/17/2023 5:00 PM
Addresses	Shipping Address	Update	Change Request	Keck Hospital of USC Orange County Pharmacy 300 Old Newport Blvd. Newport Beach, CA 92663	Keck Hospital of USC - Newport Pharmacy 330 Old Newport Blvd. RM 170 Newport Beach, CA 92663	2/10/2023 6:26 AM
Details	Last Recertification Date	Update	Recertification		8/29/2022 11:59:45 AM	8/29/2022 11:59 AM
Details	State	Update		Approved	Active	7/1/2022 12:01 AM
Contacts	Signed By	Insert	New Registration		Hanners, Rod Chief Operating Officer Keck Medicine of USC 3234428677	4/21/2022 2:01 PM
Details	340B ID	Update	New Registration		CAN050660-09	4/21/2022 2:01 PM
Details	Entity Name	Update	New Registration	USC NORRIS CANCER HOSPITAL	USC Norris Cancer Hospital	4/21/2022 2:01 PM
Details	Entity Subname	Update	New Registration	Keck Medicine of USC - Huntington Beach Healthcare Center	Keck Medicine of USC - Huntington Beach Healthcare Center - Hematology, Oncology, Neurology	4/21/2022 2:01 PM
Dates	Participating Approval Date	Update	New Registration		4/21/2022 2:01:00 PM	4/21/2022 2:01 PM
Details	State	Update	New Registration	Pending	Approved	4/21/2022 2:01 PM
Dates	Signed By Date	Update	New Registration		4/19/2022 1:56:55 PM	4/21/2022 2:01 PM
Dates	Start Date	Update	New Registration		7/1/2022 12:00:00 AM	4/21/2022 2:01 PM
Addresses	Main Address	Insert	New Registration		19582 Beach Blvd. Suite 206 Huntington Beach, CA 92648	4/14/2022 1:06 PM
Addresses	Billing Address	Insert	New Registration		USC Norris Cancer Hospital 1441 Eastlake Avenue Los Angeles, CA 90033	4/14/2022 1:06 PM
Addresses	Shipping Address	Insert	New Registration		USC Norris Cancer Hospital 1441 Eastlake Avenue Los Angeles, CA 90033	4/14/2022 1:06 PM
Addresses	Shipping Address	Insert	New Registration		Keck Medicine of USC - Huntington Beach Healthcare Center 19582 Beach Blvd. Suite 206 Huntington Beach, CA 92648	4/14/2022 1:06 PM
Addresses	Shipping Address	Insert	New Registration		KECK HOSPITAL OF USC - HUNTINGTON BEACH TREATMENT CENTER 19582 BEACH BLVD STE 115L Huntington Beach, CA 92648	4/14/2022 1:06 PM
Addresses	Shipping Address	Insert	New Registration		Keck Hospital of USC Orange County Pharmacy 300 Old Newport Blvd. Newport Beach, CA 92663	4/14/2022 1:06 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770728438	4/14/2022 1:06 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/14/2022 1:06 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1417554528	4/14/2022 1:06 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/14/2022 1:06 PM
Contacts	Authorizing Official	Insert	New Registration		Hanners, Rod Chief Operating Officer Keck Medicine of USC 3234428677	4/14/2022 1:06 PM
Contacts	Primary Contact	Insert	New Registration		Azizian, Krist Chief Pharmacy Officer Keck Medicine of USC 3238653588	4/14/2022 1:06 PM
Details	Assistance Received From Date	Insert	New Registration			4/14/2022 1:06 PM
Details	Assistance Received To Date	Insert	New Registration			4/14/2022 1:06 PM
Details	Last Recertification Date	Insert	New Registration			4/14/2022 1:06 PM
Details	Grant Number	Insert	New Registration			4/14/2022 1:06 PM
Details	340B ID	Insert	New Registration			4/14/2022 1:06 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/14/2022 1:06 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/14/2022 1:06 PM
Details	Medicare Provider Number	Insert	New Registration		050660	4/14/2022 1:06 PM
Details	Entity Name	Insert	New Registration		USC NORRIS CANCER HOSPITAL	4/14/2022 1:06 PM
Details	NOFO Number	Insert	New Registration			4/14/2022 1:06 PM
Details	Program Code	Insert	New Registration		CAN	4/14/2022 1:06 PM
Details	Entity Subname	Insert	New Registration		Keck Medicine of USC - Huntington Beach Healthcare Center	4/14/2022 1:06 PM
Dates	Participating Approval Date	Insert	New Registration			4/14/2022 1:06 PM
Details	State	Insert	New Registration		Pending	4/14/2022 1:06 PM
Dates	Registration Date	Insert	New Registration		4/14/2022 1:06:20 PM	4/14/2022 1:06 PM
Dates	Signed By Date	Insert	New Registration			4/14/2022 1:06 PM
Dates	Start Date	Insert	New Registration			4/14/2022 1:06 PM
Terminations	Termination Comments	Insert	New Registration			4/14/2022 1:06 PM
Terminations	Termination Date	Insert	New Registration			4/14/2022 1:06 PM
Terminations	Termination Effective Date	Insert	New Registration			4/14/2022 1:06 PM
Terminations	Termination Reason	Insert	New Registration			4/14/2022 1:06 PM