Provider Demographics
NPI:1417209438
Name:OPTUM INFUSION SERVICES 401, LLC
Entity Type:Organization
Organization Name:OPTUM INFUSION SERVICES 401, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:BURR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-310-4701
Mailing Address - Street 1:11000 OPTUM CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-2503
Mailing Address - Country:US
Mailing Address - Phone:800-328-5979
Mailing Address - Fax:
Practice Address - Street 1:4610 NORTHGATE BLVD
Practice Address - Street 2:STE. 130
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834-1122
Practice Address - Country:US
Practice Address - Phone:877-698-5415
Practice Address - Fax:844-425-0128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-15
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1417209438Medicaid
CAPHY53890OtherCA PHARMACY LICENSE
FA4352162OtherDEA LICENSE
CAPHY53890OtherCA PHARMACY LICENSE