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OPTUM PHARMACY 702, LLC
RRC380014-00 GOOD SAMARITAN HOSPITAL CORVALLIS
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Covered Entity Details
Entity Name
GOOD SAMARITAN HOSPITAL CORVALLIS
Subdivision Name
Type
Rural Referral Center
340B ID
RRC380014-00
Entity Address
3600 NW SAMARITAN DRIVE
CORVALLIS, OR 97330
Medicare Provider Number
380014
Participating Start Date
10/1/2018
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/12/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Daniel Smith, VP Finance/CFO
(541) 768-5390
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
10/12/2018
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