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OPTUM PHARMACY 705, LLC
CAH031312-00 Bisbee Hospital Association dba Copper Queen Community Hospital
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Covered Entity Details
Entity Name
Bisbee Hospital Association dba Copper Queen Community Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031312-00
Entity Address
101 Cole Ave
Bisbee, AZ 85603
Medicare Provider Number
031312
Participating Start Date
4/1/2013
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
1100 LEE BRANCH LN
BIRMINGHAM, AL 35242-7298
Pharmacy Comments
Contract Details
Approval Date
1/6/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/26/2024
Ownership change
Contacts
Covered Entity Signing Official
Heather A Lundstrom, Chief Financial Officer
(520) 432-6450
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/6/2021
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