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OPTUM PHARMACY 702, LLC
DSH050026 GROSSMONT HOSPITAL
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Covered Entity Details
Entity Name
GROSSMONT HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050026
Entity Address
5555 GROSSMONT CENTER DRIVE
LA MESA, CA 91942
Medicare Provider Number
050026
Participating Start Date
7/1/2004
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/12/2018
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
Daniel Kindron, CFO
(619) 740-4743
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
4/12/2018
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