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OPTUM INFUSION SERVICES 402, LLC
DSH050136 NorCal HealthConnect LLC, DBA Petaluma Valley Hospital
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Covered Entity Details
Entity Name
NorCal HealthConnect LLC, DBA Petaluma Valley Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050136
Entity Address
400 N. MCDOWELL BLVD
PETALUMA, CA 94954
Medicare Provider Number
050136
Participating Start Date
4/1/2015
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
OPTUM INFUSION SERVICES 402, LLC
Pharmacy Address
2300 MAIN ST STE 150
IRVINE, CA 92614-6223
Pharmacy Comments
Contract Details
Approval Date
4/15/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/13/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Bharatha Naotunne, CFO
(707) 431-6523
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2024
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