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OPTUM INFUSION SERVICES 404 LLC
DSH500050 PeaceHealth Southwest Medical Center
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Covered Entity Details
Entity Name
PeaceHealth Southwest Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500050
Entity Address
400 NE Mother Joseph Place
VANCOUVER, WA 98664
Medicare Provider Number
500050
Participating Start Date
4/1/2005
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
OPTUM INFUSION SERVICES 404 LLC
Pharmacy Address
2065 NE WILLIAMSON CT
STE B
BEND, OR 97701
Pharmacy Comments
Contract Details
Approval Date
4/2/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Sean Gregory, Chief Executive
(360) 514-2082
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/2/2020
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