Contract Pharmacy Details

OPTUM INFUSION SERVICES 208, INC.
DSH110091 Piedmont Rockdale Hospital, Inc.

Covered Entity Details

Entity Name

Piedmont Rockdale Hospital, Inc.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH110091

Entity Address

1412 Milstead Ave NE
CONYERS, GA 30012

Medicare Provider Number

110091

Participating Start Date

4/1/2019

Last Recertification Date

8/29/2024

Pharmacy Details

Pharmacy Name

OPTUM INFUSION SERVICES 208, INC.

Pharmacy Address

556 ARBOR HILL RD STE F
KERNERSVILLE, NC 27284-3321

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

1/1/2024
Pharmacy closed

Contacts

Covered Entity Signing Official

Marty Wynn, CFO
(770) 736-2420

Contract Pharmacy Representative

Avella
Nancy McCutcheon, Sr VP of Strategic Sales
(651) 983-0677

Signed By Date

4/15/2021

340B Drug Pricing Program Database