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OPTUM PHARMACY 702, LLC
RRC160153-00 MercyOne Siouxland Medical Center
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Covered Entity Details
Entity Name
MercyOne Siouxland Medical Center
Subdivision Name
Type
Rural Referral Center
340B ID
RRC160153-00
Entity Address
801 FIFTH STREET
SIOUX CITY, IA 51101
Medicare Provider Number
160153
Participating Start Date
10/1/2018
Last Recertification Date
9/4/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/16/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Beth Hughes, President
(712) 279-2018
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/16/2020
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