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KECK MEDICINE OF USC SPECIALTY 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
KECK MEDICINE OF USC SPECIALTY PHARMACY
Pharmacy Address
1000 S FREMONT AVE STE 10150
ALHAMBRA, CA 91803-8800
Pharmacy Comments
Contract Details
Approval Date
10/13/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Rod Hanners, Chief Operating Officer
(323) 442-8677
Contract Pharmacy Representative
Raffi Svadjian, Executive Director Retail Pharmacy Services
(323) 442-6121
Signed By Date
10/13/2015
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