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OPTUM PHARMACY 702, LLC
RRC500002-00 PROV ST MARY MEDICAL CENTER
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Covered Entity Details
Entity Name
PROV ST MARY MEDICAL CENTER
Subdivision Name
Providence St. Mary Medical Center
Type
Rural Referral Center
340B ID
RRC500002-00
Entity Address
401 W POPLAR ST.
WALLA WALLA, WA 99362-2846
Medicare Provider Number
500002
Participating Start Date
7/1/2024
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/7/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Susan Blackburn, CHIEF EXECUTIVE
(509) 897-2290
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/7/2021
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