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OPTUM PHARMACY 702, LLC
DSH380061 PROVIDENCE PORTLAND MEDICAL CENTER
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Covered Entity Details
Entity Name
PROVIDENCE PORTLAND MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380061
Entity Address
4805 NE GLISAN ST
PORTLAND, OR 97213
Medicare Provider Number
380061
Participating Start Date
7/1/2015
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/17/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Paul Gaden, Chief Executive
(503) 215-8603
Contract Pharmacy Representative
Optum
NATHAN WHITE, Vice President Sales - TPA & Hospital
(813) 949-1951
Signed By Date
4/17/2017
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