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OPTUM PHARMACY 704, INC.
DSH050262 RONALD REAGAN UCLA MEDICAL CENTER
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Covered Entity Details
Entity Name
RONALD REAGAN UCLA MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050262
Entity Address
757 WESTWOOD PLAZA
LOS ANGELES, CA 90095
Medicare Provider Number
050262
Participating Start Date
1/1/1998
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 704, INC.
Pharmacy Address
5627 UNIVERSITY HTS STE 108
SAN ANTONIO, TX 78249
Pharmacy Comments
Contract Details
Approval Date
1/6/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Paul Staton, CFO
(310) 267-9308
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/6/2021
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