Contract Pharmacy Details

OPTUM PHARMACY 702, LLC
RRC130049-00 KOOTENAI HEALTH INC

Covered Entity Details

Entity Name

KOOTENAI HEALTH INC

Subdivision Name

Type

Rural Referral Center

340B ID

RRC130049-00

Entity Address

2003 KOOTENAI HEALTH WAY
COEUR DALENE, ID 83814

Medicare Provider Number

130049

Participating Start Date

7/1/2025

Last Recertification Date

Pharmacy Details

Pharmacy Name

OPTUM PHARMACY 702, LLC

Pharmacy Address

1050 PATROL RD
JEFFERSONVILLE, IN 47130

Pharmacy Comments

Contract Details

Approval Date

2/1/2019

Contract Begin Date

4/1/2019

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2021
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Kim Webb, CFO
(208) 625-4001

Contract Pharmacy Representative

Briova Rx
Joe Iovino, Manager
(412) 445-4495

Signed By Date

1/15/2019