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OPTUM PHARMACY 702, LLC
DSH420078 Prisma Health GREENVILLE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
Prisma Health GREENVILLE MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH420078
Entity Address
701 GROVE ROAD
GREENVILLE, SC 29605
Medicare Provider Number
420078
Participating Start Date
4/1/1999
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
8/4/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
James Scott Agnew, CEO
(864) 455-5286
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/15/2020
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