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OPTUM PHARMACY 702, LLC
DSH210001 MERITUS MEDICAL CENTER
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Covered Entity Details
Entity Name
MERITUS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210001
Entity Address
11116 MEDICAL CAMPUS ROAD
HAGERSTOWN, MD 21742
Medicare Provider Number
210001
Participating Start Date
7/1/2018
Last Recertification Date
8/23/2024
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
Tom T Chan, CFO
(301) 790-8101
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/15/2020
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