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OPTUM PHARMACY 707, INC
CAH051337-00 HAZEL HAWKINS MEM. HOSPITAL
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Covered Entity Details
Entity Name
HAZEL HAWKINS MEM. HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH051337-00
Entity Address
911 SUNSET DRIVE
HOLLISTER, CA 95023
Medicare Provider Number
051337
Participating Start Date
10/1/2021
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 707, INC
Pharmacy Address
4900 RIVERGRADE RD STE E110
IRWINDALE, CA 91706-1401
Pharmacy Comments
Contract Details
Approval Date
10/15/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/12/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
MARK ROBINSON, CFO
(831) 636-2604
Contract Pharmacy Representative
Optum
Maleta Beahan, asst secretary
(224) 231-1594
Signed By Date
10/15/2021
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