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OPTUM PHARMACY 702, LLC
HM1592 CHILDREN'S MEDICAL CENTER OF DALLAS
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Covered Entity Details
Entity Name
CHILDREN'S MEDICAL CENTER OF DALLAS
Subdivision Name
NORTH TEXAS HEMOPHILIA CENTER
Type
Comprehensive Hemophilia Treatment Center
340B ID
HM1592
Entity Address
1935 Medical District Drive
DALLAS, TX 75235
Grant Number
5H30MC24051-13-00
Participating Start Date
10/1/1996
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/13/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David T Berry, CHST President, System Clinical Operations
(214) 456-2143
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Sr VP of Strategic Sales
(651) 983-0677
Signed By Date
7/13/2020
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