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OPTUM PHARMACY 702, LLC
DSH380050 Sky Lakes Medical Center
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Covered Entity Details
Entity Name
Sky Lakes Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380050
Entity Address
2865 Daggett Avenue
Klamath Falls, OR 97601
Medicare Provider Number
380050
Participating Start Date
7/1/2012
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/9/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Richard E. Rico, Vice President/CFO
(541) 274-6150
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
10/9/2024
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