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OPTUM PHARMACY 705, LLC
DSH500054 PROVIDENCE HEALTH & SERVICES - WASHINGTON
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Covered Entity Details
Entity Name
PROVIDENCE HEALTH & SERVICES - WASHINGTON
Subdivision Name
PROVIDENCE SACRED HEART MEDICAL CENTER AND CHILDREN'S HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH500054
Entity Address
101 WEST 8TH AVENUE
SPOKANE, WA 99204
Medicare Provider Number
500054
Participating Start Date
1/1/2005
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
1100 LEE BRANCH LN
BIRMINGHAM, AL 35242-7298
Pharmacy Comments
Contract Details
Approval Date
7/3/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Helen Andrus, CFO
(509) 474-3307
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
7/3/2018
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