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OPTUM PHARMACY 705, LLC
DSH270049 Intermountain Health St Vincent Regional Hospital
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Covered Entity Details
Entity Name
Intermountain Health St Vincent Regional Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH270049
Entity Address
1233 N. 30th Street
Billings, MT 59101
Medicare Provider Number
270049
Participating Start Date
10/1/2012
Last Recertification Date
8/19/2024
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
11/7/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Pam Palagi, VP of Finacial Services
(406) 723-2414
Contract Pharmacy Representative
Optum
McKinnlee Bowman, National Account Manager
(855) 828-9834
Signed By Date
4/18/2022
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