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OPTUM PHARMACY 706, INC.
DSH050231 POMONA VALLEY HOSPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
POMONA VALLEY HOSPITAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050231
Entity Address
1798 NORTH GAREY AVENUE
POMONA, CA 91767
Medicare Provider Number
050231
Participating Start Date
1/1/2007
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 706, INC.
Pharmacy Address
30-30 47TH AVENUE
SUITE 410
LONG ISLAND CITY, NY 11101
Pharmacy Comments
Contract Details
Approval Date
1/17/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/15/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
Michael A.G. Nelson, Vice President
(909) 865-9843
Contract Pharmacy Representative
Optum
NATHAN WHITE, Vice President Sales - TPA & Hospital
(813) 949-1951
Signed By Date
1/17/2017
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