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OPTUM PHARMACY 702, LLC
DSH010065 RUSSELL MEDICAL CENTER
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Covered Entity Details
Entity Name
RUSSELL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010065
Entity Address
3316 Highway 280
ALEXANDER CITY, AL 35010
Medicare Provider Number
010065
Participating Start Date
1/1/2008
Last Recertification Date
9/8/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/8/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
L.E. Peace III, CEO
(256) 329-7188
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
7/8/2019
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