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OPTUM PHARMACY 806, INC.
DSH050696 Keck Hospital of USC
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Covered Entity Details
Entity Name
Keck Hospital of USC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050696
Entity Address
1500 SAN PABLO STREET
LOS ANGELES, CA 90033
Medicare Provider Number
050696
Participating Start Date
4/1/2010
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 806, INC.
Pharmacy Address
2288 AUBURN BLVD
STE. 102
SACRAMENTO, CA 95821-1618
Pharmacy Comments
Contract Details
Approval Date
1/14/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/10/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Rod Hanners, Chief Operating Officer
(323) 442-8677
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/14/2020
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