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OPTUM PHARMACY 704, INC.
RRC230146-00 HENRY FORD HEALTH WYANDOTTE HOSPITAL
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Covered Entity Details
Entity Name
HENRY FORD HEALTH WYANDOTTE HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC230146-00
Entity Address
2333 BIDDLE
WYANDOTTE, MI 48192
Medicare Provider Number
230146
Participating Start Date
7/1/2018
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 704, INC.
Pharmacy Address
5627 UNIVERSITY HTS STE 108
SAN ANTONIO, TX 78249
Pharmacy Comments
Contract Details
Approval Date
1/16/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Doug Clark, SVP - Corporate Finance
(313) 874-5446
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Sr VP of Strategic Sales
(651) 983-0677
Signed By Date
1/16/2020
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