Contract Pharmacy Details

OPTUM PHARMACY 702, LLC
RRC460006-00 LDS HOSPITAL

Covered Entity Details

Entity Name

LDS HOSPITAL

Subdivision Name

Type

Rural Referral Center

340B ID

RRC460006-00

Entity Address

8TH AVENUE AND C STREET.
SALT LAKE CITY, UT 84143

Medicare Provider Number

460006

Participating Start Date

1/3/2022

Last Recertification Date

8/25/2022

Entity Termination Date

5/15/2023

Pharmacy Details

Pharmacy Name

OPTUM PHARMACY 702, LLC

Pharmacy Address

1050 PATROL RD
JEFFERSONVILLE, IN 47130

Pharmacy Comments

Contract Details

Approval Date

3/23/2022

Contract Begin Date

3/23/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

5/15/2023
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Mike DeMotte, Finance Director
(801) 408-2087

Contract Pharmacy Representative

Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677

Signed By Date

3/23/2022