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OPTUM PHARMACY 805, INC
DSH030064 Banner - University Medical Center Tucson
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Covered Entity Details
Entity Name
Banner - University Medical Center Tucson
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030064
Entity Address
1625 North Campbell Avenue
TUCSON, AZ 85719
Medicare Provider Number
030064
Participating Start Date
1/1/1997
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 805, INC
Pharmacy Address
1101 N CENTRAL AVE, STE 102
PHOENIX, AZ 85004-1829
Pharmacy Comments
Contract Details
Approval Date
7/16/2020
Contract Begin Date
7/16/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/24/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Brad Hipp, Chief Financial Officer
(520) 694-3446
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Sr VP of Strategic Sales
(651) 983-0677
Signed By Date
7/16/2020
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