Contract Pharmacy Details

OPTUM PHARMACY 702, LLC
DSH050454 UCSF-MEDICAL CENTER

Covered Entity Details

Entity Name

UCSF-MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH050454

Entity Address

505 PARNASSUS AVE.
SAN FRANCISCO, CA 94143

Medicare Provider Number

050454

Participating Start Date

7/1/1993

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

1/9/2018

Contract Begin Date

4/1/2018

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Sheila Antrum, SVP-AdultSvcs/President-MedCtr
(415) 353-2717

Contract Pharmacy Representative

Briova Rx
Joe Iovino, Manager
(412) 445-4495

Signed By Date

1/9/2018

340B Drug Pricing Program Database