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OPTUM PHARMACY 702, LLC
PED363306-00 Dayton Children's Hospital
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Covered Entity Details
Entity Name
Dayton Children's Hospital
Subdivision Name
Type
Children's Hospital
340B ID
PED363306-00
Entity Address
1 CHILDREN'S PLAZA
DAYTON, OH 45404
Medicare Provider Number
363306
Participating Start Date
4/1/2010
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Benjamin Goodstein, VICE PRESIDENT and Chief Ambulatory Officer
(937) 641-3450
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/15/2020
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