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OPTUM PHARMACY 801, INC.
DSH420004 MEDICAL UNIVERSITY HOSPITAL AUTHORITY
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Covered Entity Details
Entity Name
MEDICAL UNIVERSITY HOSPITAL AUTHORITY
Subdivision Name
MEDICAL UNIVERSITY HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH420004
Entity Address
169 ASHLEY AVENUE
CHARLESTON, SC 29425
Medicare Provider Number
420004
Participating Start Date
12/1/1992
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 801, INC.
Pharmacy Address
24416 N 19TH AVE
STE. 100
PHOENIX, AZ 85085
Pharmacy Comments
Contract Details
Approval Date
1/13/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Thomas C Crawford, Chief Operating Officer
(843) 792-8775
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/13/2020
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