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OPTUM PHARMACY 702, LLC
CAH531310-00 Powell Valley Healthcare
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Covered Entity Details
Entity Name
Powell Valley Healthcare
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH531310-00
Entity Address
777 Ave H
Powell, WY 82435
Medicare Provider Number
531310
Participating Start Date
1/1/2012
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/22/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Terry Odom, CEO
(307) 754-1101
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/22/2021
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