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OPTUM PHARMACY 702, LLC
CAH361316-04 BUCYRUS COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
BUCYRUS COMMUNITY HOSPITAL
Subdivision Name
Provider Based Clinic - Hill Street (PBC 124) - Physician Practice
Type
Critical Access Hospital
340B ID
CAH361316-04
Entity Address
124 Hill Street
Bucyrus, OH 44820
Medicare Provider Number
361316
Outpatient Facility Provider Number
Participating Start Date
4/1/2020
Last Recertification Date
8/28/2024
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
Contacts
Covered Entity Signing Official
Eric Draime, CFO
(419) 468-0501
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/13/2020
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