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OPTUM PHARMACY 701, LLC
DSH380004 PROVIDENCE ST. VINCENT MEDICAL CENTER
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Covered Entity Details
Entity Name
PROVIDENCE ST. VINCENT MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380004
Entity Address
9205 SW BARNES RD
PORTLAND, OR 97225
Medicare Provider Number
380004
Participating Start Date
1/1/2016
Last Recertification Date
8/28/2024
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
10/15/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Nancy S. Roberts, Chief Operating Officer
(503) 216-4609
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/15/2020
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