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OPTUM PHARMACY 702, LLC
DSH110107 Atrium Health Navicent The Medical Center
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Covered Entity Details
Entity Name
Atrium Health Navicent The Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110107
Entity Address
777 HEMLOCK ST.
MACON, GA 31201-2102
Medicare Provider Number
110107
Participating Start Date
12/1/1992
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/18/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/18/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Don McCoy Mabe, VP, Pharmacy
(704) 512-7623
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/18/2021
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