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OPTUM PHARMACY 705, LLC
PED453300-00 COOK CHILDREN'S MEDICAL CENTER
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Covered Entity Details
Entity Name
COOK CHILDREN'S MEDICAL CENTER
Subdivision Name
Type
Children's Hospital
340B ID
PED453300-00
Entity Address
801 SEVENTH AVENUE
FORT WORTH, TX 76104-2733
Medicare Provider Number
453300
Participating Start Date
2/26/2010
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
1100 LEE BRANCH LN
BIRMINGHAM, AL 35242-7298
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
7/29/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Nancy Cychol, EVP, Hospital Services
(682) 885-4340
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/15/2020
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