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OPTUM PHARMACY 702, LLC
SCH030055-00 Kingman Regional Medical Center
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Covered Entity Details
Entity Name
Kingman Regional Medical Center
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH030055-00
Entity Address
3269 Stockton Hill Road
Kingman, AZ 86409
Medicare Provider Number
030055
Participating Start Date
7/1/2013
Last Recertification Date
9/11/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/16/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/24/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tim Blanchard, CFO
(928) 681-8668
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/16/2019
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