Contract Pharmacy Details

OPTUM PHARMACY 705, LLC
DSH340047 NORTH CAROLINA BAPTIST HOSPITAL

Covered Entity Details

Entity Name

NORTH CAROLINA BAPTIST HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH340047

Entity Address

MEDICAL CENTER BOULEVARD
WINSTON-SALEM, NC 27157

Medicare Provider Number

340047

Participating Start Date

4/1/1998

Last Recertification Date

8/23/2024

Pharmacy Details

Pharmacy Name

OPTUM PHARMACY 705, LLC

Pharmacy Address

1100 LEE BRANCH LN
BIRMINGHAM, AL 35242-7298

Pharmacy Comments

Contract Details

Approval Date

10/17/2019

Contract Begin Date

1/1/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Conrad Emmerich, Sr. Vice President,Hospital & Business Services
(336) 716-8941

Contract Pharmacy Representative

Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677

Signed By Date

10/17/2019

340B Drug Pricing Program Database