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OPTUM PHARMACY 702, LLC
DSH230236 METROPOLITAN HOSPITAL
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Covered Entity Details
Entity Name
METROPOLITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230236
Entity Address
5900 BYRON CENTER AVE SW
WYOMING, MI 49519
Medicare Provider Number
230236
Participating Start Date
7/1/2004
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kris Kurtz, CFO
(616) 252-4844
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
4/15/2019
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