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OPTUM INFUSION SERVICES 550, LLC
DSH130006 ST LUKES REGIONAL MEDICAL CENTER, LTD.
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Covered Entity Details
Entity Name
ST LUKES REGIONAL MEDICAL CENTER, LTD.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH130006
Entity Address
190 EAST BANNOCK
BOISE, ID 83712
Medicare Provider Number
130006
Participating Start Date
7/1/2004
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
OPTUM INFUSION SERVICES 550, LLC
Pharmacy Address
10607 & 10611 AURORA AVE.
URBANDALE, IA 50322
Pharmacy Comments
Contract Details
Approval Date
4/15/2022
Contract Begin Date
5/18/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/4/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Peter DiDio, Vice President, Controller
(208) 381-1251
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2022
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