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OPTUM PHARMACY 702, LLC
DSH050261 Sierra View Medical Center
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Covered Entity Details
Entity Name
Sierra View Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050261
Entity Address
465 W PUTNAM AVENUE
PORTERVILLE, CA 93257
Medicare Provider Number
050261
Participating Start Date
7/1/2004
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/3/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ron Wheaton, Vice President of Professional Services/Physician Recruitment
(559) 788-6106
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
10/3/2024
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