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OPTUM PHARMACY 702, LLC
DSH470003 UNIVERSITY OF VERMONT MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY OF VERMONT MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH470003
Entity Address
111 Colchester Avenue
Burlington, VT 05401
Medicare Provider Number
470003
Participating Start Date
4/1/2005
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/14/2020
Contract Begin Date
7/23/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Christina Oliver, VP of Clinical Services
(802) 847-2805
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/14/2020
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