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OPTUM PHARMACY 702, LLC
DSH050126 Valley Presbyterian Hospital
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Covered Entity Details
Entity Name
Valley Presbyterian Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050126
Entity Address
15107 Vanowen Street
Van Nuys, CA 91405
Medicare Provider Number
050126
Participating Start Date
1/1/2012
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/15/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
LORI CARDLE, SVP Finance, CFO
(818) 902-5235
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/15/2019
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