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OPTUM PHARMACY 702, LLC
DSH050093 SAINT AGNES MEDICAL CENTER
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Covered Entity Details
Entity Name
SAINT AGNES MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050093
Entity Address
1303 E HERNDON AVE
FRESNO, CA 93720
Medicare Provider Number
050093
Participating Start Date
1/1/2014
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/7/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
NANCY HOLLINGSWORTH, CEO
(559) 450-3301
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/7/2021
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