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OPTUM PHARMACY 702, LLC
RRC500024-00 PROVIDENCE ST. PETER HOSPITAL
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Covered Entity Details
Entity Name
PROVIDENCE ST. PETER HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC500024-00
Entity Address
413 LILLY ROAD NE
OLYMPIA, WA 98506
Medicare Provider Number
500024
Participating Start Date
4/1/2020
Last Recertification Date
9/11/2024
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
Denise Marroni, CFO SWR
(360) 493-5203
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/14/2020
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