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OPTUM PHARMACY 702, LLC
CAH241367-00 Welia Health
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Covered Entity Details
Entity Name
Welia Health
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241367-00
Entity Address
301 Hwy 65 S
Mora, MN 55051
Medicare Provider Number
241367
Participating Start Date
10/1/2011
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
10/3/2022
Contract Begin Date
10/11/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/21/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Randy William Ulseth, CEO
(320) 225-3315
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/3/2022
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