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OPTUM PHARMACY 702, LLC
DSH050057 Kaweah Delta Health Care District DBA Kaweah Health
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Covered Entity Details
Entity Name
Kaweah Delta Health Care District DBA Kaweah Health
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050057
Entity Address
400 West Mineral King Avenue
Visalia, CA 93291
Medicare Provider Number
050057
Participating Start Date
7/1/2004
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/27/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
GARY K. HERBST, Chief Executive Officer
(559) 624-2330
Contract Pharmacy Representative
Optum
Nancy McCutcheon, Sr. VP of Strategic Sales
(651) 983-0677
Signed By Date
7/27/2020
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