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OPTUM PHARMACY 702, LLC
DSH200063 PENOBSCOT BAY MEDICAL CENTER
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Covered Entity Details
Entity Name
PENOBSCOT BAY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH200063
Entity Address
6 Glen Cove Dr
Rockport, ME 04856
Medicare Provider Number
200063
Participating Start Date
4/1/2006
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/14/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Linda Drinkwater, CFO
(207) 505-4104
Contract Pharmacy Representative
Optum
Nancy McCutcheon, Sr. VP of Strategic Sales
(651) 983-0677
Signed By Date
4/14/2020
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