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OPTUM PHARMACY 701, LLC
DSH500041 PEACEHEALTH ST. JOHN MEDICAL CENTER
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Covered Entity Details
Entity Name
PEACEHEALTH ST. JOHN MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500041
Entity Address
1615 DELAWARE ST
LONGVIEW, WA 98632
Medicare Provider Number
500041
Participating Start Date
7/1/2004
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
1/2/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tracey Fernandez, CFO
(360) 514-3548
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
1/2/2025
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