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OPTUM INFUSION SERVICES 401, LLC
PED053305-00 LUCILE PACKARD CHILDREN'S HOSPITAL
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Covered Entity Details
Entity Name
LUCILE PACKARD CHILDREN'S HOSPITAL
Subdivision Name
Type
Children's Hospital
340B ID
PED053305-00
Entity Address
725 WELCH ROAD
PALO ALTO, CA 94304
Medicare Provider Number
053305
Participating Start Date
1/19/2010
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
OPTUM INFUSION SERVICES 401, LLC
Pharmacy Address
455 RESERVATION RD STE G
MARINA, CA 93933-3328
Pharmacy Comments
Contract Details
Approval Date
4/14/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/2/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
Rick Stephen Majzun, COO
(650) 723-0418
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/14/2022
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