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OPTUM PHARMACY 702, LLC
CAH161367-00 PELLA REGIONAL HEALTH CENTER
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Covered Entity Details
Entity Name
PELLA REGIONAL HEALTH CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161367-00
Entity Address
404 JEFFERSON ST.
PELLA, IA 50219
Medicare Provider Number
161367
Participating Start Date
1/1/2011
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/15/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/15/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Dawnett Willis, Chief Ancillary Services Officer
(641) 621-2480
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2020
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