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OPTUM PHARMACY 800, INC.
CAH161380-00 ELLSWORTH MUNICIPAL HOSPITAL
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Covered Entity Details
Entity Name
ELLSWORTH MUNICIPAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161380-00
Entity Address
920 S OAK ST
DBA HANSEN FAMILY HOSPITAL
IOWA FALLS, IA 50126-9506
Medicare Provider Number
161380
Participating Start Date
9/1/2010
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 800, INC.
Pharmacy Address
3016 GUADALUPE ST STE A
AUSTIN, TX 78705-2861
Pharmacy Comments
Contract Details
Approval Date
1/15/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/2/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Diane Deblon, CFO
(563) 547-6677
Contract Pharmacy Representative
Avella
Tammy Sievert, 340B Implementation and Analytics Manager, Corportate
(602) 769-3073
Signed By Date
1/15/2018
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