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OPTUM PHARMACY 705, LLC
DSH520051 COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC
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Covered Entity Details
Entity Name
COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC
Subdivision Name
COLUMBIA ST MARYS HOSPITAL MILWAUKEE
Type
Disproportionate Share Hospital
340B ID
DSH520051
Entity Address
2323 N LAKE DRIVE
MILWAUKEE, WI 53211-4508
Medicare Provider Number
520051
Participating Start Date
4/1/2004
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
3539 BLUECUTT RD
COLUMBUS, MS 39705
Pharmacy Comments
Contract Details
Approval Date
7/8/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Vanessa Freitag, Vice President, Pharmacy
(715) 897-1183
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/8/2020
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