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OPTUM PHARMACY 702, LLC
DSH230059 SAINT MARY'S HEALTH CARE
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Covered Entity Details
Entity Name
SAINT MARY'S HEALTH CARE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230059
Entity Address
200 JEFFERSON SE
GRAND RAPIDS, MI 49503
Medicare Provider Number
230059
Participating Start Date
12/1/2005
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/15/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Daniel G. Green, Vice President for Finance
(616) 685-6709
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Sr VP of Strategic Sales
(651) 983-0677
Signed By Date
10/15/2019
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