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OPTUM PHARMACY 702, LLC
CAH231320-00 Trinity Health Shelby Hospital
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Covered Entity Details
Entity Name
Trinity Health Shelby Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH231320-00
Entity Address
72 SOUTH STATE STREET
SHELBY, MI 49455
Medicare Provider Number
231320
Participating Start Date
8/9/2010
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/14/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John Thomas Foss, Vice President of Operations - Lakeshore Campus
(231) 861-3029
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/14/2020
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