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OPTUM PHARMACY 705, LLC
DSH060009 Intermountain Health Lutheran Hospital
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Covered Entity Details
Entity Name
Intermountain Health Lutheran Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060009
Entity Address
12911 W 40th Ave
WHEAT RIDGE, CO 80401
Medicare Provider Number
060009
Participating Start Date
4/1/2015
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
1100 LEE BRANCH LN
BIRMINGHAM, AL 35242-7298
Pharmacy Comments
Contract Details
Approval Date
4/18/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/27/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ashley Denton, VP Finance
(303) 425-2410
Contract Pharmacy Representative
Optum
McKinnlee Bowman, National Account Manager
(855) 828-9834
Signed By Date
4/18/2022
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