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OPTUM PHARMACY 702, LLC
RRC500072-00 OLYMPIC MEDICAL CENTER
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Covered Entity Details
Entity Name
OLYMPIC MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC500072-00
Entity Address
939 CAROLINE STREET
PORT ANGELES, WA 98362
Medicare Provider Number
500072
Participating Start Date
10/1/2015
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/16/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/17/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Darryl Wolfe, Chief Executive Officer
(360) 417-7705
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/16/2021
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