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OPTUM PHARMACY 702, LLC
DSH380002 THREE RIVERS MEDICAL CENTER
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Covered Entity Details
Entity Name
THREE RIVERS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380002
Entity Address
500 S.W. RAMSEY AVE
GRANTS PASS, OR 97527
Medicare Provider Number
380002
Participating Start Date
4/1/2015
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/5/2022
Contract Begin Date
7/21/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/18/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Greg Wojtal, Chief Administrative and Finance Officer
(541) 789-4549
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/5/2022
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