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OPTUM PHARMACY 702, LLC
SCH160064-00 MERCYONE NORTH IOWA MEDICAL CENTER
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Covered Entity Details
Entity Name
MERCYONE NORTH IOWA MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH160064-00
Entity Address
1000 4TH STREET SW
MASON CITY, IA 50401
Medicare Provider Number
160064
Participating Start Date
4/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
3/7/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mark Trammel, HM VP Finance
(641) 428-7984
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/10/2025
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