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OPTUM PHARMACY 702, LLC
DSH050136 NorCal HealthConnect LLC, DBA Petaluma Valley Hospital
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Covered Entity Details
Entity Name
NorCal HealthConnect LLC, DBA Petaluma Valley Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050136
Entity Address
400 N. MCDOWELL BLVD
PETALUMA, CA 94954
Medicare Provider Number
050136
Participating Start Date
4/1/2015
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/2/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kevin Klockenga, CEO
(707) 522-1520
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/15/2020
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