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OPTUM PHARMACY 702, LLC
DSH050557 Sutter Valley Hospitals DBA Memorial Medical Center
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Covered Entity Details
Entity Name
Sutter Valley Hospitals DBA Memorial Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050557
Entity Address
1700 COFFEE ROAD
MODESTO, CA 95355
Medicare Provider Number
050557
Participating Start Date
9/2/2008
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
4/22/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David Scott Wartelle, CFO - Greater Central Valley Market
(209) 572-7009
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/22/2024
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