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OPTUM PHARMACY 806, INC.
DSH060103 AdventHealth Avista
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Covered Entity Details
Entity Name
AdventHealth Avista
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060103
Entity Address
100 Health Park Drive
Louisville, CO 80027
Medicare Provider Number
060103
Participating Start Date
1/1/2012
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 806, INC.
Pharmacy Address
2288 AUBURN BLVD
STE. 102
SACRAMENTO, CA 95821-1618
Pharmacy Comments
Contract Details
Approval Date
7/13/2020
Contract Begin Date
7/13/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/12/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Carol Travis, CFO
(720) 627-1230
Contract Pharmacy Representative
Avella
Tammy Sievert, 340B Implementation and Analytics Manager, Corportate
(602) 769-3073
Signed By Date
7/13/2020
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