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OPTUM PHARMACY 702, LLC
CAH051328-00 TAHOE FOREST HOSPITAL
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Covered Entity Details
Entity Name
TAHOE FOREST HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH051328-00
Entity Address
10121 PINE AVENUE
TRUCKEE, CA 96161
Medicare Provider Number
051328
Participating Start Date
1/1/2011
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/4/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
CRYSTAL BETTS, CHIEF FINANCIAL OFFICER
(530) 582-6656
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/4/2022
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