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OPTUM PHARMACY 702, LLC
DSH060009 Intermountain Health Lutheran Hospital
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Covered Entity Details
Entity Name
Intermountain Health Lutheran Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060009
Entity Address
12911 W 40th Ave
WHEAT RIDGE, CO 80401
Medicare Provider Number
060009
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
10/4/2022
Contract Begin Date
11/8/2022
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
Ashley Denton, VP Finance
(303) 425-2410
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/4/2022
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