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OPTUM PHARMACY 702, LLC
RRC360180-00 CLEVELAND CLINIC HOSPITAL
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Covered Entity Details
Entity Name
CLEVELAND CLINIC HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC360180-00
Entity Address
9500 EUCLID AVENUE
CLEVELAND, OH 44195
Medicare Provider Number
360180
Participating Start Date
4/1/2020
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/15/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tim Longville, Chief Accounting Officer and Controller
(216) 636-7416
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2020
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