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OPTUM PHARMACY 702, LLC
DSH230089 WILLIAM BEAUMONT HOSPITAL D/B/A Corewell Health Beaumont Grosse Pointe Hospital
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Covered Entity Details
Entity Name
WILLIAM BEAUMONT HOSPITAL D/B/A Corewell Health Beaumont Grosse Pointe Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230089
Entity Address
468 CADIEUX ROAD
GROSSE POINTE, MI 48230
Medicare Provider Number
230089
Participating Start Date
1/1/2017
Last Recertification Date
8/21/2024
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
Carolyn Wilson, Chief Operating Officer
(947) 522-3338
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
4/15/2019
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