Contract Pharmacy Details

OPTUM PHARMACY 801, INC.
DSH130049 KOOTENAI HEALTH INC

Covered Entity Details

Entity Name

KOOTENAI HEALTH INC

Subdivision Name

KOOTENAI HEALTH

Type

Disproportionate Share Hospital

340B ID

DSH130049

Entity Address

2003 Kootenai Health Way
COEUR DALENE, ID 83814

Medicare Provider Number

130049

Participating Start Date

7/1/2021

Last Recertification Date

8/20/2024

Entity Termination Date

7/1/2025

Pharmacy Details

Pharmacy Name

OPTUM PHARMACY 801, INC.

Pharmacy Address

24416 N 19TH AVE
STE. 100
PHOENIX, AZ 85085

Pharmacy Comments

Contract Details

Approval Date

6/29/2021

Contract Begin Date

7/1/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2025
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Kim Webb, CFO
(208) 625-4001

Contract Pharmacy Representative

Briova Rx
Joe Iovino, Manager
(412) 445-4495

Signed By Date

6/29/2021