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OPTUM PHARMACY 702, LLC
DSH030089 BANNER THUNDERBIRD MEDICAL CENTER
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Covered Entity Details
Entity Name
BANNER THUNDERBIRD MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030089
Entity Address
5555 W. Thunderbird Road
Glendale, AZ 85306
Medicare Provider Number
030089
Participating Start Date
1/1/2007
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/22/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jeremy Williams, Chief Financial Officer
(623) 524-4083
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/22/2020
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