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OPTUM PHARMACY 801, INC.
DSH050254 MARSHALL HOSPITAL
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Covered Entity Details
Entity Name
MARSHALL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050254
Entity Address
1100 MARSHALL WAY
PLACERVILLE, CA 95667
Medicare Provider Number
050254
Participating Start Date
1/1/2016
Last Recertification Date
8/12/2024
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
4/13/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Siri Nelson, CEO
(707) 349-8127
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/13/2021
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