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OPTUM PHARMACY 702, LLC
DSH360025 FIRELANDS REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
FIRELANDS REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360025
Entity Address
1111 HAYES AVENUE
SANDUSKY, OH 44870
Medicare Provider Number
360025
Participating Start Date
1/1/2017
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/9/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Daniel J. Moncher, Executive Vice President & CFO
(419) 557-7793
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
7/9/2019
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