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OPTUM PHARMACY 702, LLC
RWII49684 Munson Medical Center
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Covered Entity Details
Entity Name
Munson Medical Center
Subdivision Name
Thomas Judd Care Center
Type
Ryan White Part B
340B ID
RWII49684
Entity Address
5041 N. Royal Dr.
Suite 1
Traverse City, MI 49684
Grant Number
X07HA00044
Participating Start Date
4/1/2015
Last Recertification Date
2/11/2025
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
Contract Termination Date
Termination Reason
7/15/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Chris Podges, Chief Information Officer
(231) 935-6548
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/14/2020
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