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OPTUM PHARMACY 702, LLC
CAH131301-00 BOUNDARY COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
BOUNDARY COMMUNITY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH131301-00
Entity Address
6640 KANIKSU
BONNERS FERRY, ID 83805
Medicare Provider Number
131301
Participating Start Date
1/1/2023
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/9/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
April Bennett, CEO
(208) 267-4850
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/9/2023
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