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OPTUM PHARMACY 702, LLC
DSH340075 Blue Ridge HealthCare Hospitals, Inc
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Covered Entity Details
Entity Name
Blue Ridge HealthCare Hospitals, Inc
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH340075
Entity Address
2201 SOUTH STERLING STREET
MORGANTON, NC 28655
Medicare Provider Number
340075
Participating Start Date
12/6/2005
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/11/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/7/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
KATHY BAILEY, CEO
(828) 580-5586
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
7/11/2019
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