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OPTUM PHARMACY 702, LLC
DSH410011 Landmark Medical Center
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Covered Entity Details
Entity Name
Landmark Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH410011
Entity Address
115 Cass ave
Woonsocket, RI 02895
Medicare Provider Number
410011
Participating Start Date
10/1/2018
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
7/6/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
scott brown, cfo
(401) 769-4100 Ext: 6601
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/6/2020
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