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UNIV OF SOUTH CALIF PHARMACY
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
UNIV OF SOUTH CALIF PHARMACY
Pharmacy Address
3601 TROUSDALE PKWY
LOS ANGELES, CA 90089
Pharmacy Comments
Contract Details
Approval Date
8/30/2010
Contract Begin Date
9/1/2010
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/22/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
8/15/2010
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