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OPTUM PHARMACY 701, LLC
CAH171385-01 Coffey County Hospital
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Covered Entity Details
Entity Name
Coffey County Hospital
Subdivision Name
WAVERLY MEDICAL CLINIC - PRIMARY CARE
Type
Critical Access Hospital
340B ID
CAH171385-01
Entity Address
302 PEARSON
WAVERLY, KS 66781
Medicare Provider Number
171385
Outpatient Facility Provider Number
173983
Participating Start Date
4/1/2018
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
1/15/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Samantha Jo Kuhlmann, Director of Informatics
(620) 364-2121 Ext: 4221
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
1/15/2025
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