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OPTUM PHARMACY 704, INC.
DSH340113 CAROLINAS MEDICAL CENTER
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Covered Entity Details
Entity Name
CAROLINAS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH340113
Entity Address
1000 BLYTHE BLVD
CHARLOTTE, NC 28203
Medicare Provider Number
340113
Participating Start Date
8/1/1993
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 704, INC.
Pharmacy Address
5627 UNIVERSITY HTS STE 108
SAN ANTONIO, TX 78249
Pharmacy Comments
Contract Details
Approval Date
1/18/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
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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