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OPTUM PHARMACY 705, LLC
DSH050100 SHARP MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
SHARP MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050100
Entity Address
7901 FROST STREET
SAN DIEGO, CA 92123
Medicare Provider Number
050100
Participating Start Date
7/1/2004
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
1100 LEE BRANCH LN
BIRMINGHAM, AL 35242-7298
Pharmacy Comments
Contract Details
Approval Date
4/11/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/14/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
TIM SMITH, CEO
(858) 939-4082
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
4/11/2018
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