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OPTUM PHARMACY 702, LLC
HM29203 Prisma Health
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Covered Entity Details
Entity Name
Prisma Health
Subdivision Name
DBA Hemostasis and Thrombosis Center of South Carolina
Type
Comprehensive Hemophilia Treatment Center
340B ID
HM29203
Entity Address
14 Richland Medical Park Drive
Suite 410
COLUMBIA, SC 29203
Grant Number
H30MC24046
Participating Start Date
10/1/2009
Last Recertification Date
2/13/2025
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
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/15/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Stephanie Ambrose, Medical Director - Hemophilia Treatment Center
(803) 434-3508
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/15/2020
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