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OPTUM PHARMACY 702, LLC
CAH461303-00 IHC Health Services INC dba INTERMOUNTAIN HEALTH SANPETE VALLEY HOSPITAL
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Covered Entity Details
Entity Name
IHC Health Services INC dba INTERMOUNTAIN HEALTH SANPETE VALLEY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH461303-00
Entity Address
1100 SOUTH MEDICAL DRIVE
MT. PLEASANT, UT 84647
Medicare Provider Number
461303
Participating Start Date
10/1/2014
Last Recertification Date
8/13/2024
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
Aaron Wood, CEO/Administrator-Sanpete
(435) 462-4123
Contract Pharmacy Representative
Optum RX
Joseph Iovino, VP
(412) 445-4495
Signed By Date
4/15/2019
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