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OPTUM PHARMACY 702, LLC
RRC200024-00 CENTRAL MAINE MEDICAL CENTER
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Covered Entity Details
Entity Name
CENTRAL MAINE MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC200024-00
Entity Address
300 MAIN STREET
LEWISTON, ME 04240-4500
Medicare Provider Number
200024
Participating Start Date
10/1/2017
Last Recertification Date
9/13/2021
Entity Termination Date
4/1/2022
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/17/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Sean Cheetham, Taxation Manager
(207) 795-7533
Contract Pharmacy Representative
Optum RX
Joseph Iovino, VP
(412) 445-4495
Signed By Date
7/17/2018
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