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OPTUM PHARMACY 702, LLC
DSH020012 FAIRBANKS MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
FAIRBANKS MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH020012
Entity Address
1650 COWLES STREET
FAIRBANKS, AK 99701-5998
Medicare Provider Number
020012
Participating Start Date
9/9/2005
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/1/2020
Contract Begin Date
8/4/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/13/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Clint F Brooks, COO
(907) 458-5307
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/1/2020
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