Contract Pharmacy Details

OPTUM PHARMACY 801, INC.
DSH050262 RONALD REAGAN UCLA MEDICAL CENTER

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 801, INC.

Pharmacy Address

24416 N 19TH AVE
STE. 100
PHOENIX, AZ 85085

Pharmacy Comments

Contract Details

Approval Date

4/8/2021

Contract Begin Date

7/1/2021

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

4/8/2021

340B Drug Pricing Program Database