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OPTUM PHARMACY 702, LLC
DSH500079 GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500079
Entity Address
401 15th Avenue SE
PUYALLUP, WA 98372
Medicare Provider Number
500079
Participating Start Date
1/1/2022
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/20/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Florence Chang, President
(253) 403-7355
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/20/2022
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