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OPTUM PHARMACY 702, LLC
DSH070007 LAWRENCE & MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
LAWRENCE & MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH070007
Entity Address
365 MONTAUK AVENUE
NEW LONDON, CT 06320-4700
Medicare Provider Number
070007
Participating Start Date
7/1/2019
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/14/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/15/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Douglas Payne, Director, Reimbursement Yale New Haven Health System
(203) 688-4878
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/14/2021
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