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OPTUM INFUSION SERVICES 553, LLC
CAH161374-00 SHELBY CO CHRIS A MYRTUE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
SHELBY CO CHRIS A MYRTUE MEMORIAL HOSPITAL
Subdivision Name
DBA MYRTUE MEDICAL CENTER
Type
Critical Access Hospital
340B ID
CAH161374-00
Entity Address
1213 GARFIELD AVE
HARLAN, IA 51537
Medicare Provider Number
161374
Participating Start Date
4/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM INFUSION SERVICES 553, LLC
Pharmacy Address
6531 MERIDIEN DR
SUITE 113
RALEIGH, NC 27616
Pharmacy Comments
Contract Details
Approval Date
4/17/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/24/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Barry Jacobsen, CEO
(712) 755-4315
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/17/2023
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