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OPTUM PHARMACY 702, LLC
CAH321300-00 SIERRA VISTA HOSPITAL
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Covered Entity Details
Entity Name
SIERRA VISTA HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH321300-00
Entity Address
800 EAST 9TH AVE.
TRUTH OR CONSEQUENCES, NM 87901-1961
Medicare Provider Number
321300
Participating Start Date
7/1/2018
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/15/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Eric Lee Stokes, CEO
(575) 894-2111
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/15/2021
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