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OPTUM PHARMACY 702, LLC
DSH050150 SIERRA NEVADA MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
SIERRA NEVADA MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050150
Entity Address
155 GLASSON WAY
GRASS VALLEY, CA 95945
Medicare Provider Number
050150
Participating Start Date
7/1/2016
Last Recertification Date
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/11/2019
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
David Hall, VP and CFO
(530) 274-6099
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/11/2019
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