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OPTUM PHARMACY 702, LLC
DSH320090 SANTA FE MEDICAL CENTER
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Covered Entity Details
Entity Name
SANTA FE MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320090
Entity Address
4801 BECKNER ROAD
SANTA FE, NM 87507
Medicare Provider Number
320090
Participating Start Date
10/1/2020
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/14/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David Scott Graham, VP-PDS Clinical Support Srvc
(505) 841-1872
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/14/2020
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