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OPTUM PHARMACY 702, LLC
DSH010033 UNIVERSITY OF ALABAMA HOSPITAL
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Covered Entity Details
Entity Name
UNIVERSITY OF ALABAMA HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010033
Entity Address
619 S. 19th Street
BIRMINGHAM, AL 35249
Medicare Provider Number
010033
Participating Start Date
12/1/1992
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
4/16/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/30/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
WILL FERNIANY, CEO, UAB HEALTH SYSTEM
(205) 975-4844
Contract Pharmacy Representative
Optum RX
Joseph Iovino, VP
(412) 445-4495
Signed By Date
4/16/2019
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