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OPTUM PHARMACY 806, INC.
DSH380075 PROVIDENCE MEDFORD MEDICAL CENTER
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Covered Entity Details
Entity Name
PROVIDENCE MEDFORD MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380075
Entity Address
1111 CRATER LAKE AVENUE
MEDFORD, OR 97504
Medicare Provider Number
380075
Participating Start Date
7/1/2015
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 806, INC.
Pharmacy Address
2288 AUBURN BLVD
STE. 102
SACRAMENTO, CA 95821-1618
Pharmacy Comments
Contract Details
Approval Date
1/14/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Paul Kristopher Ziegele, CFO
(541) 732-6772
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/14/2021
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