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OPTUM PHARMACY 705, LLC
DSH110007 PHOEBE PUTNEY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
PHOEBE PUTNEY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110007
Entity Address
417 WEST THIRD AVENUE
ALBANY, GA 31701
Medicare Provider Number
110007
Participating Start Date
10/1/2003
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
1100 LEE BRANCH LN
BIRMINGHAM, AL 35242-7298
Pharmacy Comments
Contract Details
Approval Date
1/10/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brian Church, CFO & CAO
(229) 312-4066
Contract Pharmacy Representative
Optum Rx/BriovaRx/Avella
Joseph L Iovino, Vice President, 340B Sepcialty Program
(412) 445-4495
Signed By Date
1/10/2020
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