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OPTUM PHARMACY 701, LLC
DSH500058 Kadlec Regional Medical Center
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Covered Entity Details
Entity Name
Kadlec Regional Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500058
Entity Address
888 SWIFT BOULEVARD
RICHLAND, WA 99352
Medicare Provider Number
500058
Participating Start Date
7/1/2007
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
10/13/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Spencer Dwayne Harris, CFO
(509) 942-2708
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
10/13/2024
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