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OPTUM PHARMACY 702, LLC
CAH051333-00 Ridgecrest Regional Hospital
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Covered Entity Details
Entity Name
Ridgecrest Regional Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH051333-00
Entity Address
1081 N. China Lake Blvd.
Ridgecrest, CA 93555
Medicare Provider Number
051333
Participating Start Date
10/1/2013
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/9/2021
Contract Begin Date
4/19/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/6/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
James Suver, CEO
(760) 499-3902
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/9/2021
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