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OPTUM PHARMACY 705, LLC
CAH171381-00 Hosp Dist #1 of Dickinson
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Covered Entity Details
Entity Name
Hosp Dist #1 of Dickinson
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH171381-00
Entity Address
511 NE 10th Street
Abilene, KS 67410
Medicare Provider Number
171381
Participating Start Date
10/1/2012
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
11142 RENNER BLVD
LENEXA, KS 66219
Pharmacy Comments
Contract Details
Approval Date
4/26/2021
Contract Begin Date
4/27/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/14/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Reginald Harold Courtois, CEO
(785) 263-6610
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/26/2021
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