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OPTUM PHARMACY 701, LLC
DSH050128 TRI-CITY MEDICAL CENTER
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Covered Entity Details
Entity Name
TRI-CITY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050128
Entity Address
4002 VISTA WAY
OCEANSIDE, CA 92056-4506
Medicare Provider Number
050128
Participating Start Date
1/1/2019
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
10/16/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ray Rivas, Chief Financial Officer
(760) 940-3352
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/16/2023
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