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OPTUM PHARMACY 702, LLC
PED093300-00 Children's National Medical Center
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Covered Entity Details
Entity Name
Children's National Medical Center
Subdivision Name
Type
Children's Hospital
340B ID
PED093300-00
Entity Address
111 Michigan Avenue, NW
Washington, DC 20010-2970
Medicare Provider Number
093300
Participating Start Date
10/1/2012
Last Recertification Date
9/4/2024
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
5/18/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kathleen Gorman, EVP, Patient Care services & Chief Operating Officer
(202) 476-2939
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2020
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