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OPTUM INFUSION SERVICES 403, LLC
PED053301-00 CHILDRENS HOSP & RES CNTR OAKLAND
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Covered Entity Details
Entity Name
CHILDRENS HOSP & RES CNTR OAKLAND
Subdivision Name
Type
Children's Hospital
340B ID
PED053301-00
Entity Address
747 52ND STREET
OAKLAND, CA 94609-1809
Medicare Provider Number
053301
Participating Start Date
10/1/2019
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
OPTUM INFUSION SERVICES 403, LLC
Pharmacy Address
170 PROFESSIONAL CENTER DR
STE C
ROHNERT PARK, CA 94928-2169
Pharmacy Comments
Contract Details
Approval Date
7/7/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
Jamie Christine Phillips, Chief Operating Officer
(415) 353-9116
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/7/2020
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