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OPTUM PHARMACY 702, LLC
DSH110023 AdventHealth Gordon
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Covered Entity Details
Entity Name
AdventHealth Gordon
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110023
Entity Address
1035 RED BUD ROAD NE
CALHOUN, GA 30701
Medicare Provider Number
110023
Participating Start Date
4/1/2008
Last Recertification Date
9/6/2023
Entity Termination Date
7/1/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/13/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Alan Guyton, Regional CFO
(706) 879-4710
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/13/2020
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