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OPTUM PHARMACY 702, LLC
DSH340166 Atrium Health University City
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Covered Entity Details
Entity Name
Atrium Health University City
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH340166
Entity Address
8800 North Tryon Street
Charlotte, NC 28262
Medicare Provider Number
340166
Participating Start Date
4/1/2012
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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