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OPTUM PHARMACY 702, LLC
DSH230207 McLaren Oakland
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Covered Entity Details
Entity Name
McLaren Oakland
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230207
Entity Address
50 N Perry St
Pontiac, MI 48342-2217
Medicare Provider Number
230207
Participating Start Date
1/1/2005
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/18/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lynn Marcotte, CFO
(248) 338-5691
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
4/18/2019
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