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OPTUM PHARMACY 702, LLC
DSH330197 CANTON-POTSDAM HOSPITAL
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Covered Entity Details
Entity Name
CANTON-POTSDAM HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330197
Entity Address
50 LEROY STREET
POTSDAM, NY 13676
Medicare Provider Number
330197
Participating Start Date
1/1/2009
Last Recertification Date
8/20/2024
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
Donna M McGregor, System CFO
(315) 261-5451
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2021
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