340B Drug Pricing Program Database
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DSH050696AD Keck Hospital of USC (Terminated)
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Main Details
Name
Keck Hospital of USC
Subdivision Name
Keck Medicine of USC - Huntington Beach Treatment Center - Infusion
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH050696AD
Medicare Provider Number
050696
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/12/2018
Participating Start Date
4/1/2018
Participating Approval Date
2/8/2018
Last Recertification Date
8/25/2020
Termination Date
Termination Reason
10/1/2021
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 Boulevard
115
Huntington Beach, CA 92648
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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