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CORAM HEALTHCARE CORP OF SOUTHERN CALIFO
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
CORAM HEALTHCARE CORP OF SOUTHERN CALIFO
Pharmacy Address
DBA CORAM CVS/SPECIALTY INFUSION SERVICE
2710 MEDIA CENTER DRIVE, BLDG. #6,
SUITE 150
LOS ANGELES, CA 90065
Pharmacy Comments
Contract Details
Approval Date
1/13/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Rod Hanners, Chief Operating Officer
(323) 442-8677
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/13/2022
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