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OPTUM PHARMACY 701, LLC
DSH060010 POUDRE VALLEY HOSPITAL
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Covered Entity Details
Entity Name
POUDRE VALLEY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060010
Entity Address
1024 S. LEMAY AVENUE
FT. COLLINS, CO 80524
Medicare Provider Number
060010
Participating Start Date
4/1/2022
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
8131 W BOSTIAN RD STE A350
WOODINVILLE, WA 98072-5029
Pharmacy Comments
Contract Details
Approval Date
4/15/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David Charles Thompson, Chief Financial Officer
(970) 237-7011
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2022
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