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OPTUM PHARMACY 705, LLC
DSH450684 MEMORIAL HERMANN NORTHEAST HOSPITAL
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Covered Entity Details
Entity Name
MEMORIAL HERMANN NORTHEAST HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450684
Entity Address
18951 N. Memorial Drive
Humble, TX 77338
Medicare Provider Number
450684
Participating Start Date
9/9/2005
Last Recertification Date
8/19/2024
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
7/28/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Randy Reid, VP, Finance
(281) 540-7802
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/15/2020
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