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OPTUM PHARMACY 702, LLC
DSH050516 MERCY SAN JUAN MEDICAL CENTER
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Covered Entity Details
Entity Name
MERCY SAN JUAN MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050516
Entity Address
6501 COYLE AVENUE
CARMICHAEL, CA 95608
Medicare Provider Number
050516
Participating Start Date
4/1/2005
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/10/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/16/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Robin Rogness, CFO
(916) 537-5153
Contract Pharmacy Representative
Optum RX
Joseph Iovino, VP
(412) 445-4495
Signed By Date
10/10/2019
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