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OPTUM PHARMACY 701, LLC
RRC140046-00 SSM HEALTH GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
SSM HEALTH GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140046-00
Entity Address
1 GOOD SAMARITAN WAY
MT. VERNON, IL 62864
Medicare Provider Number
140046
Participating Start Date
7/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
8131 W BOSTIAN RD STE A350
WOODINVILLE, WA 98072-5029
Pharmacy Comments
Contract Details
Approval Date
5/5/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Eileen Lamm, Regional Vice President-Finance
(314) 994-6219
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/14/2025
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