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OPTUM PHARMACY 702, LLC
DSH110046 PIEDMONT WALTON HOSPITAL, INC.
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Covered Entity Details
Entity Name
PIEDMONT WALTON HOSPITAL, INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110046
Entity Address
2151 WEST SPRING STREET
MONROE, GA 30655
Medicare Provider Number
110046
Participating Start Date
4/1/2019
Last Recertification Date
8/23/2021
Entity Termination Date
1/1/2022
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
Contract Termination Date
Termination Reason
1/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Marty Wynn, CFO
(770) 736-2420
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2021
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