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OPTUM PHARMACY 801, INC.
DSH500003 SKAGIT VALLEY HOSPITAL
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Covered Entity Details
Entity Name
SKAGIT VALLEY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500003
Entity Address
1415 EAST KINCAID
MOUNT VERNON, WA 98274-4126
Medicare Provider Number
500003
Participating Start Date
7/1/2006
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 801, INC.
Pharmacy Address
24416 N 19TH AVE
STE. 100
PHOENIX, AZ 85085
Pharmacy Comments
Contract Details
Approval Date
7/13/2020
Contract Begin Date
7/13/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Paul Ishizuka, CFO
(360) 814-5838
Contract Pharmacy Representative
Optum
Dave Miller, Account Manager
(847) 917-1731
Signed By Date
7/13/2020
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