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OPTUM PHARMACY 702, LLC
DSH460004 IHC Health Services Inc. DBA Intermountain Health McKay-Dee Hospital
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Covered Entity Details
Entity Name
IHC Health Services Inc. DBA Intermountain Health McKay-Dee Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH460004
Entity Address
4401 HARRISON BLVD
OGDEN, UT 84403
Medicare Provider Number
460004
Participating Start Date
6/15/2020
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/13/2022
Contract Begin Date
4/18/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/7/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Trever Porter, Finance Dir-MK
(801) 387-3767
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/13/2022
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