Contract Pharmacy Details

OPTUM PHARMACY 702, LLC
DSH520087 Gundersen Lutheran Medical Center, Inc.

Covered Entity Details

Entity Name

Gundersen Lutheran Medical Center, Inc.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH520087

Entity Address

1900 South Ave
La Crosse, WI 54601

Medicare Provider Number

520087

Participating Start Date

7/1/2012

Last Recertification Date

9/6/2024

Pharmacy Details

Pharmacy Name

OPTUM PHARMACY 702, LLC

Pharmacy Address

1050 PATROL RD
JEFFERSONVILLE, IN 47130

Pharmacy Comments

Contract Details

Approval Date

9/2/2020

Contract Begin Date

9/2/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Kay P Marsyla, Director, Reimbursement
(608) 775-0171

Contract Pharmacy Representative

Avella/BriovaRx
Paul Leschinert, National Account Manager,340B Sales
(847) 409-0200

Signed By Date

9/2/2020

340B Drug Pricing Program Database