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OPTUM PHARMACY 702, LLC
DSH360085 THE OHIO STATE UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
THE OHIO STATE UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360085
Entity Address
410 W. 10th Avenue
COLUMBUS, OH 43210
Medicare Provider Number
360085
Participating Start Date
7/1/2016
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/12/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mark Larmore, Chief Financial Officer
(614) 685-9420
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
7/12/2019
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