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OPTUM PHARMACY 702, LLC
CAH061328-00 UPPER SAN JUAN HEALTH SERVICE DISTRICT
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Covered Entity Details
Entity Name
UPPER SAN JUAN HEALTH SERVICE DISTRICT
Subdivision Name
PAGOSA SPRINGS MEDICAL CENTER
Type
Critical Access Hospital
340B ID
CAH061328-00
Entity Address
95 SOUTH PAGOSA BLVD
PAGOSA SPRINGS, CO 81147
Medicare Provider Number
061328
Participating Start Date
4/1/2011
Last Recertification Date
9/5/2024
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
Chelle Keplinger, CFO
(970) 507-3803
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/15/2021
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