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CORAM HEALTHCARE CORP OF SOUTHERN CALIFO
DSH050471 PIH HEALTH GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
PIH HEALTH GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050471
Entity Address
1225 Wilshire Blvd
LOS ANGELES, CA 90017-2395
Medicare Provider Number
050471
Participating Start Date
7/1/2008
Last Recertification Date
8/27/2024
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
7/5/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/18/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
ALAN INO, CFO
(213) 977-2910
Contract Pharmacy Representative
Emilee Young, Branch Manager
(323) 352-5200
Signed By Date
7/5/2017
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