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OPTUM PHARMACY 702, LLC
PED103300-00 JOHNS HOPKINS ALL CHILDREN'S HOSPITAL, INC.
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Covered Entity Details
Entity Name
JOHNS HOPKINS ALL CHILDREN'S HOSPITAL, INC.
Subdivision Name
Type
Children's Hospital
340B ID
PED103300-00
Entity Address
501 6th Ave. South
St. Petersburg, FL 33701
Medicare Provider Number
103300
Participating Start Date
9/30/2010
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/15/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Thomas D Kmetz, President
(727) 767-6873
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2021
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