Provider Demographics
NPI:1679676639
Name:UNIVERSITY OF SOUTHERN CALIFORNIA
Entity Type:Organization
Organization Name:UNIVERSITY OF SOUTHERN CALIFORNIA
Other - Org Name:USC MEDICAL PLAZA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:323-442-1354
Mailing Address - Street 1:1510 SAN PABLO ST
Mailing Address - Street 2:STE 144
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-4604
Mailing Address - Country:US
Mailing Address - Phone:323-442-5770
Mailing Address - Fax:323-442-5970
Practice Address - Street 1:1510 SAN PABLO ST
Practice Address - Street 2:STE 144
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5320
Practice Address - Country:US
Practice Address - Phone:323-442-5770
Practice Address - Fax:323-442-5970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
CAPHY371953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1996506OtherPK
CA1679676639Medicaid
CA1679676639Medicaid