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OPTUM PHARMACY 806, INC.
DSH060012 St. Mary-Corwin Hospital
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Covered Entity Details
Entity Name
St. Mary-Corwin Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060012
Entity Address
1008 Minnequa Avenue
Pueblo, CO 81004
Medicare Provider Number
060012
Participating Start Date
4/1/2014
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 806, INC.
Pharmacy Address
2288 AUBURN BLVD
STE. 102
SACRAMENTO, CA 95821-1618
Pharmacy Comments
Contract Details
Approval Date
10/14/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael Cafasso, Chief Executive Officer
(719) 557-4678
Contract Pharmacy Representative
Avella
Tammy Sievert, 340B Implementation and Analytics Manager, Corportate
(602) 769-3073
Signed By Date
10/14/2019
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