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OPTUM INFUSION SERVICES 200, INC
DSH110034 AU Medical Center, Inc.
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Covered Entity Details
Entity Name
AU Medical Center, Inc.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110034
Entity Address
1120 15TH ST.
AUGUSTA, GA 30912
Medicare Provider Number
110034
Participating Start Date
12/1/1992
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
OPTUM INFUSION SERVICES 200, INC
Pharmacy Address
5895 CORE RD
STE 417
NORTH CHARLESTON, SC 29406
Pharmacy Comments
Contract Details
Approval Date
10/10/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Timothy M. Gaillard, Chief Operating Officer
(706) 721-7228
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/10/2019
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