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OPTUM PHARMACY 702, LLC
SCH460019-00 Uintah Basin Medical Center
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Covered Entity Details
Entity Name
Uintah Basin Medical Center
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH460019-00
Entity Address
250 West 300 North
Roosevelt, UT 84066
Medicare Provider Number
460019
Participating Start Date
7/1/2012
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/14/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brent Hales, CFO
(435) 722-6164
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
1/14/2025
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