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OPTUM PHARMACY 702, LLC
DSH050009 ST Joseph Health Northern California LLC-DBA Queen of the Valley Medical Center
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Covered Entity Details
Entity Name
ST Joseph Health Northern California LLC-DBA Queen of the Valley Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050009
Entity Address
1000 TRANCAS STREET
NAPA, CA 94558
Medicare Provider Number
050009
Participating Start Date
4/1/2016
Last Recertification Date
8/16/2024
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
9/29/2023
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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