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OPTUM PHARMACY 705, LLC
DSH500003 SKAGIT VALLEY HOSPITAL
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Covered Entity Details
Entity Name
SKAGIT VALLEY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500003
Entity Address
1415 EAST KINCAID
MOUNT VERNON, WA 98274-4126
Medicare Provider Number
500003
Participating Start Date
7/1/2006
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
11142 RENNER BLVD
LENEXA, KS 66219
Pharmacy Comments
Contract Details
Approval Date
4/15/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/28/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
Paul Ishizuka, CFO
(360) 814-5838
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2021
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