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OPTUM PHARMACY 701, LLC
DSH060023 St. Mary's Hospital & Medical Center, Inc dba Intermountain Health St. Mary's Regional Hospital
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Covered Entity Details
Entity Name
St. Mary's Hospital & Medical Center, Inc dba Intermountain Health St. Mary's Regional Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060023
Entity Address
2635 N. 7TH STREET
GRAND JUNCTION, CO 81501
Medicare Provider Number
060023
Participating Start Date
10/1/2014
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
4100 S SAGINAW ST STE D
FLINT, MI 48507
Pharmacy Comments
Contract Details
Approval Date
4/19/2022
Contract Begin Date
4/20/2022
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
Terri Chinn, CFO
(970) 298-2020
Contract Pharmacy Representative
Optum
McKinnlee Bowman, National Account Manager
(855) 828-9834
Signed By Date
4/19/2022
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