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OPTUM PHARMACY 702, LLC
CAH131326-00 IHC Health Services Inc. DBA Intermountain Health Cassia Regional Hospital
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Covered Entity Details
Entity Name
IHC Health Services Inc. DBA Intermountain Health Cassia Regional Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131326-00
Entity Address
1501 Hiland Avenue
Burley, ID 83318
Medicare Provider Number
131326
Participating Start Date
4/1/2013
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/27/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ben Smalley, Administrator
(208) 677-6441
Contract Pharmacy Representative
Optum RX
Joseph Iovino, VP
(412) 445-4495
Signed By Date
4/15/2019
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