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OPTION CARE
DSH050696 Keck Hospital of USC
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Covered Entity Details
Entity Name
Keck Hospital of USC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050696
Entity Address
1500 SAN PABLO STREET
LOS ANGELES, CA 90033
Medicare Provider Number
050696
Participating Start Date
4/1/2010
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
OPTION CARE
Pharmacy Address
OPTION CARE ENTERPRISES, INC.
5800 DISTRICT BLVD UNIT 200
BAKERSFIELD, CA 93313-2148
Pharmacy Comments
Contract Details
Approval Date
10/14/2019
Contract Begin Date
10/15/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Rod Hanners, Chief Operating Officer
(323) 442-8677
Contract Pharmacy Representative
Option Care
Derek Bilyk, Program Manager, Health Systems
(224) 813-1283
Signed By Date
10/14/2019
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