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OPTUM PHARMACY 702, LLC
PED073300-00 CONNECTICUT CHILDREN'S MEDICAL CENTER
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Covered Entity Details
Entity Name
CONNECTICUT CHILDREN'S MEDICAL CENTER
Subdivision Name
Type
Children's Hospital
340B ID
PED073300-00
Entity Address
282 WASHINGTON STREET
HARTFORD, CT 06106
Medicare Provider Number
073300
Participating Start Date
7/1/2010
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/10/2020
Contract Begin Date
7/28/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Gil Peri, President & COO
(860) 885-8587
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/10/2020
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