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OPTUM PHARMACY 702, LLC
DSH050191 ST. MARY MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. MARY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050191
Entity Address
1050 LINDEN AVENUE
LONG BEACH, CA 90813-3393
Medicare Provider Number
050191
Participating Start Date
1/1/2017
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/13/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/15/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Leon Choiniere, Vice President/Chief Financial Officer
(562) 491-9191
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/13/2021
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