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OPTUM PHARMACY 702, LLC
DSH050121 Adventist Medical Center
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Covered Entity Details
Entity Name
Adventist Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050121
Entity Address
115 mall drive
HANFORD, CA 93230
Medicare Provider Number
050121
Participating Start Date
1/1/2008
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/9/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Timothy Michael Haydock, CFO
(559) 537-0050
Contract Pharmacy Representative
Briovarx
Jeff grosklag, CFO
(855) 677-2515
Signed By Date
4/9/2018
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