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OPTUM PHARMACY 702, LLC
CAH531316-00 Memorial Hospital of Carbon County
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Covered Entity Details
Entity Name
Memorial Hospital of Carbon County
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH531316-00
Entity Address
2221 W. Elm St.
Rawlins, WY 82301-0460
Medicare Provider Number
531316
Participating Start Date
1/1/2012
Last Recertification Date
9/10/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/13/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jon Frederick Smith, Chief Financial Officer
(307) 324-8237
Contract Pharmacy Representative
Memorial Hospital of Carbon County
Jon Frederick Smith, Chief Financial Officer
(307) 324-8237
Signed By Date
7/13/2021
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