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OPTUM PHARMACY 702, LLC
RRC460010-00 IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER
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Covered Entity Details
Entity Name
IHC Health Services Inc. dba INTERMOUNTAIN HEALTH INTERMOUNTAIN MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC460010-00
Entity Address
5121 S COTTONWOOD ST
MURRAY, UT 84107
Medicare Provider Number
460010
Participating Start Date
6/8/2022
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
8/29/2022
Contract Begin Date
8/30/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Royce Stephens, Finance Director
(801) 507-7948
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
8/29/2022
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