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OPTUM PHARMACY 702, LLC
DSH050133 RIDEOUT MEMORIAL HOSPITAL DBA Adventist Health and Rideout
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Covered Entity Details
Entity Name
RIDEOUT MEMORIAL HOSPITAL DBA Adventist Health and Rideout
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050133
Entity Address
726 4TH STREET
MARYSVILLE, CA 95901
Medicare Provider Number
050133
Participating Start Date
7/2/2018
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/16/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ed Gonzalez, CFO
(530) 751-4010
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/16/2019
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