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OPTUM PHARMACY 702, LLC
CAH051316-00 Fairchild Medical Center
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Covered Entity Details
Entity Name
Fairchild Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH051316-00
Entity Address
444 Bruce St
Yreka, CA 96097
Medicare Provider Number
051316
Participating Start Date
7/1/2013
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/14/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kelly Martin, CFO
(530) 841-6235
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/14/2023
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