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USC MEDICAL PLAZA 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 MEDICAL PLAZA PHARMACY
Pharmacy Address
1510 SAN PABLO ST STE 144
LOS ANGELES, CA 90033-5394
Pharmacy Comments
Contract Details
Approval Date
8/30/2010
Contract Begin Date
9/1/2010
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
8/12/2010
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