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OPTUM PHARMACY 702, LLC
DSH060028 Saint Joseph Hospital, Inc. DBA Intermountain Health Saint Joseph Hospital
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Covered Entity Details
Entity Name
Saint Joseph Hospital, Inc. DBA Intermountain Health Saint Joseph Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060028
Entity Address
1375 EAST 19TH AVENUE
DENVER, CO 80218
Medicare Provider Number
060028
Participating Start Date
7/1/2016
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
1/13/2023
Contract Begin Date
1/23/2023
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
Brad Membel, VP Finance, CFO
(303) 812-4936
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/13/2023
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