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OPTUM PHARMACY 702, LLC
CAH241356-00 MILLE LACS HOSPITAL
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Covered Entity Details
Entity Name
MILLE LACS HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241356-00
Entity Address
200 N Elm St
ONAMIA, MN 56359
Medicare Provider Number
241356
Participating Start Date
4/1/2015
Last Recertification Date
8/12/2024
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
11/4/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/31/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Bill Nelson, CEO
(320) 532-2580
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/13/2020
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