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OPTUM PHARMACY 702, LLC
DSH050195 WASHINGTON HOSPITAL HEALTHCARE SYSTEM
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Covered Entity Details
Entity Name
WASHINGTON HOSPITAL HEALTHCARE SYSTEM
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050195
Entity Address
2000 MOWRY AVENUE
FREMONT, CA 94538
Medicare Provider Number
050195
Participating Start Date
7/1/2010
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
10/14/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Edward Fayen, Exec VP & Chief of Operations
(510) 818-6513
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/14/2022
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