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OPTUM PHARMACY 702, LLC
DSH050112 SANTA MONICA UCLAMC AND ORTHOPAEDIC HOSPITAL
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Covered Entity Details
Entity Name
SANTA MONICA UCLAMC AND ORTHOPAEDIC HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050112
Entity Address
1250 16TH STREET
SANTA MONICA, CA 90404-1249
Medicare Provider Number
050112
Participating Start Date
7/1/2009
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/9/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/30/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Paul Staton, CFO
(310) 267-9308
Contract Pharmacy Representative
Optum RX
Joseph Iovino, VP
(412) 445-4495
Signed By Date
7/9/2018
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