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OPTUM PHARMACY 702, LLC
DSH010039 HUNTSVILLE HOSPITAL
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Covered Entity Details
Entity Name
HUNTSVILLE HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010039
Entity Address
101 SIVLEY ROAD
HUNTSVILLE, AL 35801
Medicare Provider Number
010039
Participating Start Date
4/1/2020
Last Recertification Date
9/2/2020
Entity Termination Date
12/1/2020
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
12/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kelli Powers, CFO
(256) 265-8818
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/14/2020
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