Contract Pharmacy Details

OPTUM PHARMACY 702, LLC
DSH110034 AU Medical Center, Inc.

Covered Entity Details

Entity Name

AU Medical Center, Inc.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH110034

Entity Address

1120 15TH ST.
AUGUSTA, GA 30912

Medicare Provider Number

110034

Participating Start Date

12/1/1992

Last Recertification Date

8/22/2024

Pharmacy Details

Pharmacy Name

OPTUM PHARMACY 702, LLC

Pharmacy Address

1050 PATROL RD
JEFFERSONVILLE, IN 47130

Pharmacy Comments

Contract Details

Approval Date

7/13/2018

Contract Begin Date

10/1/2018

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Lee Ann Liska, Chief Executive Officer
(706) 721-6569

Contract Pharmacy Representative

Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677

Signed By Date

7/13/2018

340B Drug Pricing Program Database