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OPTUM PHARMACY 702, LLC
DSH050025 UCSD MEDICAL CENTER
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Covered Entity Details
Entity Name
UCSD MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050025
Entity Address
200 WEST ARBOR DRIVE
SAN DIEGO, CA 92103
Medicare Provider Number
050025
Participating Start Date
12/1/1992
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/6/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lori Donaldson, CFO
(619) 543-6613
Contract Pharmacy Representative
Optum
NATHAN WHITE, Vice President Sales - TPA & Hospital
(813) 949-1951
Signed By Date
7/6/2017
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