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OPTUM PHARMACY 702, LLC
DSH500003 SKAGIT VALLEY HOSPITAL
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Covered Entity Details
Entity Name
SKAGIT VALLEY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH500003
Entity Address
1415 EAST KINCAID
MOUNT VERNON, WA 98274-4126
Medicare Provider Number
500003
Participating Start Date
7/1/2006
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/16/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
THOMAS LITAKER, CFO
(360) 445-8505
Contract Pharmacy Representative
Briova
Joseph L Lovino, Manager, 340B Specialty Program
(412) 445-4495
Signed By Date
10/16/2017
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