340B Drug Pricing Program Database
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DSH050353B PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE (Terminated)
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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
No
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
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