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OPTUM PHARMACY 702, LLC
DSH460007 IHC Health Services Inc. DBA Intermountain Health Cedar City Hospital
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Covered Entity Details
Entity Name
IHC Health Services Inc. DBA Intermountain Health Cedar City Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH460007
Entity Address
1303 NORTH MAIN ST
CEDAR CITY, UT 84721
Medicare Provider Number
460007
Participating Start Date
7/1/2020
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
6/11/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/27/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Craig Dale Corry, Finance Director
(435) 868-5819
Contract Pharmacy Representative
Optum RX
Joseph Iovino, VP
(412) 445-4495
Signed By Date
6/10/2020
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