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OPTUM PHARMACY 702, LLC
SCH230133-00 MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH230133-00
Entity Address
825 N. CENTER AVENUE
GAYLORD, MI 49735
Medicare Provider Number
230133
Participating Start Date
8/11/2010
Last Recertification Date
8/27/2024
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
Mark Hepler, CFO
(231) 935-6702
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2021
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