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OPTUM PHARMACY 701, LLC
CAH261314-00 HERMANN AREA HOSPITAL DISTRICT
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Covered Entity Details
Entity Name
HERMANN AREA HOSPITAL DISTRICT
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261314-00
Entity Address
509 WEST 18TH STREET
HERMANN, MO 65041
Medicare Provider Number
261314
Participating Start Date
8/11/2010
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
4/14/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Bill S Hellebusch, Administrator
(573) 486-2191 Ext: 216
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
4/14/2025
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