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OPTUM PHARMACY 701, LLC
DSH060013 Mercy Hospital
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Covered Entity Details
Entity Name
Mercy Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060013
Entity Address
1010 THREE SPRINGS BLVD.
DURANGO, CO 81301
Medicare Provider Number
060013
Participating Start Date
1/1/2020
Last Recertification Date
9/10/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
8131 W BOSTIAN RD STE A350
WOODINVILLE, WA 98072-5029
Pharmacy Comments
Contract Details
Approval Date
10/12/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jane Strobel, Chief Financial Officer
(970) 764-3909
Contract Pharmacy Representative
Avella
Tammy Sievert, 340B Implementation and Analytics Manager, Corportate
(602) 769-3073
Signed By Date
10/12/2020
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