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USC I.D.S. 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
USC I.D.S. PHARMACY
Pharmacy Address
1441 EASTLAKE AVE
SUITE 2407
LOS ANGELES, CA 90089-0112
Pharmacy Comments
Contract Details
Approval Date
10/7/2010
Contract Begin Date
10/7/2010
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/24/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Thomas Jackiewicz, Senior VP and CEO for Keck Medicine of USC
(323) 442-9775
Signed By Date
8/24/2010
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