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OPTUM PHARMACY 702, LLC
DSH320022 PLAINS REGIONAL MEDICAL CENTER - CLOVIS
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Covered Entity Details
Entity Name
PLAINS REGIONAL MEDICAL CENTER - CLOVIS
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320022
Entity Address
2100 NORTH DR MARTIN LUTHER KING JR BLVD
CLOVIS, NM 88101
Medicare Provider Number
320022
Participating Start Date
4/1/2005
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/15/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Sandra C. Podley, VP Operations PDS
(505) 923-5364
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
1/15/2018
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